- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,173.94 / $2,173.94 / $2,173.94
| Facility | | $2,173.94 | $2,173.94 | $2,173.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,791.78 / $1,791.78 / $2,173.94
| Professional | | $1,791.78 | $1,791.78 | $2,173.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,412.55 / $3,993.46 / $4,062.48
| Professional | | $3,412.55 | $3,993.46 | $4,062.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,465.00 / $3,499.65 / $4,400.55
| Professional | | $3,465.00 | $3,499.65 | $4,400.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.12 / $2,173.94 / $13,407.77
| Facility | | $1,454.12 | $2,173.94 | $13,407.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.88 / $1,467.26 / $2,110.19
| Professional | | $1,011.88 | $1,467.26 | $2,110.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.43 / $1,467.26 / $2,450.25
| Professional | | $838.43 | $1,467.26 | $2,450.25 |