- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,152.01 / $2,152.01 / $2,152.01
| Facility | | $2,152.01 | $2,152.01 | $2,152.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.10 / $2,152.01 / $2,541.46
| Professional | | $2,013.10 | $2,152.01 | $2,541.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,890.11 / $3,507.29 / $4,718.43
| Facility | | $2,890.11 | $3,507.29 | $4,718.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.54 / $2,437.73 / $2,876.52
| Professional | | $1,779.54 | $2,437.73 | $2,876.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.30 / $2,268.16 / $7,407.00
| Professional | | $1,840.30 | $2,268.16 | $7,407.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,705.60 / $2,133.62 / $2,968.79
| Professional | | $1,705.60 | $2,133.62 | $2,968.79 |