- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.75 / $2,281.50 / $3,053.70
| Facility | | $1,491.75 | $2,281.50 | $3,053.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.75 / $1,526.85 / $2,018.25
| Professional | | $1,491.75 | $1,526.85 | $2,018.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $423.14 / $1,531.28 / $3,233.82
| Professional | | $423.14 | $1,531.28 | $3,233.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,417.25 / $3,389.17 / $4,183.13
| Facility | | $2,417.25 | $3,389.17 | $4,183.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.85 / $2,036.85 / $2,036.85
| Professional | | $2,036.85 | $2,036.85 | $2,036.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.75 / $2,106.00 / $8,336.25
| Facility | | $1,491.75 | $2,106.00 | $8,336.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $1,053.00 / $8,739.90
| Professional | | $737.10 | $1,053.00 | $8,739.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.10 / $1,053.00 / $1,984.91
| Professional | | $737.10 | $1,053.00 | $1,984.91 |