- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.10 / $1,875.10 / $2,257.29
| Facility | | $1,875.10 | $1,875.10 | $2,257.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.70 / $2,069.44 / $2,257.29
| Professional | | $1,736.70 | $2,069.44 | $2,257.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,945.93 / $4,484.01 / $5,494.97
| Professional | | $3,945.93 | $4,484.01 | $5,494.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,573.44 / $4,391.39 / $5,735.04
| Professional | | $2,573.44 | $4,391.39 | $5,735.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.10 / $2,970.68 / $3,837.39
| Facility | | $1,875.10 | $2,970.68 | $3,837.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.78 / $4,517.42 / $13,048.80
| Professional | | $2,352.78 | $4,517.42 | $13,048.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.78 / $4,266.46 / $5,880.38
| Professional | | $2,352.78 | $4,266.46 | $5,880.38 |