- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,296.64 / $2,296.64 / $2,296.64
| Facility | | $2,296.64 | $2,296.64 | $2,296.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.10 / $2,296.64 / $2,411.46
| Professional | | $2,013.10 | $2,296.64 | $2,411.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,471.24 / $4,212.52 / $5,667.18
| Facility | | $3,471.24 | $4,212.52 | $5,667.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.74 / $2,603.75 / $3,072.43
| Professional | | $1,900.74 | $2,603.75 | $3,072.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.57 / $2,424.59 / $7,918.87
| Professional | | $1,895.57 | $2,424.59 | $7,918.87 |
- 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
- $1,870.88 / $2,287.88 / $3,242.86
| Professional | | $1,870.88 | $2,287.88 | $3,242.86 |