- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,311.31 / $3,311.31
| Facility | | $1,819.70 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $1,995.26
| Professional | | $1,479.11 | $1,737.80 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,949.84
| Facility | | $1,905.46 | $1,905.46 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,548.13 / $6,606.93
| Facility | | $1,862.09 | $3,548.13 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $10,715.19 / $10,715.19
| Professional | | $2,570.40 | $10,715.19 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $2,238.72
| Professional | | $933.25 | $1,000.00 | $2,238.72 |