- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,287.42 / $2,287.42 / $2,287.42
| Facility | | $2,287.42 | $2,287.42 | $2,287.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,899.77 / $1,899.77 / $2,287.42
| Professional | | $1,899.77 | $1,899.77 | $2,287.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,495.03 / $4,132.35 / $4,185.39
| Professional | | $3,495.03 | $4,132.35 | $4,185.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,611.25 / $3,647.36 / $4,586.29
| Professional | | $3,611.25 | $3,647.36 | $4,586.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,899.77 / $2,287.42 / $17,045.09
| Facility | | $1,899.77 | $2,287.42 | $17,045.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.99 / $1,462.21 / $2,118.07
| Professional | | $1,010.99 | $1,462.21 | $2,118.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.67 / $1,845.10 / $2,321.55
| Professional | | $770.67 | $1,845.10 | $2,321.55 |