- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,807.25 / $1,807.25 / $1,997.67
| Facility | | $1,807.25 | $1,807.25 | $1,997.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.19 / $1,822.70 / $2,086.44
| Professional | | $1,763.19 | $1,822.70 | $2,086.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.25 / $2,490.73 / $2,984.18
| Professional | | $2,373.25 | $2,490.73 | $2,984.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.36 / $2,026.15 / $2,036.23
| Professional | | $1,425.36 | $2,026.15 | $2,036.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $3,033.98
| Professional | | $40.00 | $50.00 | $3,033.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.29 / $1,757.29 / $1,757.29
| Professional | | $1,757.29 | $1,757.29 | $1,757.29 |