- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,934.40 / $1,934.40 / $1,934.40
| Facility | | $1,934.40 | $1,934.40 | $1,934.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.31 / $1,960.19 / $2,412.52
| Professional | | $1,573.31 | $1,960.19 | $2,412.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,936.70 / $2,437.87 / $2,925.44
| Professional | | $1,936.70 | $2,437.87 | $2,925.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.75 / $1,406.76 / $1,406.76
| Professional | | $1,195.75 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,835.97 / $13,890.95 / $14,397.39
| Facility | | $2,835.97 | $13,890.95 | $14,397.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.60 / $1,411.48 / $1,977.54
| Professional | | $868.60 | $1,411.48 | $1,977.54 |