- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $2,884.03
| Professional | | $1,380.38 | $1,949.84 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,168.69 / $4,265.80
| Professional | | $3,548.13 | $4,168.69 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $4,677.35
| Professional | | $3,630.78 | $3,715.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $16,595.87
| Facility | | $1,905.46 | $2,344.23 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $3,890.45
| Professional | | $1,288.25 | $1,905.46 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $1,548.82 / $2,041.74
| Facility | | $204.17 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,570.40 / $3,890.45
| Professional | | $1,230.27 | $2,570.40 | $3,890.45 |