- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.83 / $1,665.83 / $1,665.83
| Facility | | $1,665.83 | $1,665.83 | $1,665.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.96 / $1,372.96 / $1,665.83
| Professional | | $1,372.96 | $1,372.96 | $1,665.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,615.03 / $3,060.18 / $3,113.07
| Professional | | $2,615.03 | $3,060.18 | $3,113.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,655.00 / $2,681.55 / $3,371.85
| Professional | | $2,655.00 | $2,681.55 | $3,371.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,114.33 / $1,665.83 / $10,273.09
| Facility | | $1,114.33 | $1,665.83 | $10,273.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.38 / $1,124.19 / $2,303.08
| Professional | | $775.38 | $1,124.19 | $2,303.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.40 / $1,550.75 / $1,877.39
| Professional | | $642.40 | $1,550.75 | $1,877.39 |