- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,765.44 / $2,765.44 / $2,956.11
| Facility | | $2,765.44 | $2,765.44 | $2,956.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.04 / $2,556.23 / $3,201.96
| Professional | | $1,960.04 | $2,556.23 | $3,201.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,228.99 / $1,602.62 / $2,179.75
| Facility | | $1,228.99 | $1,602.62 | $2,179.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.98 / $2,691.00 / $3,057.29
| Professional | | $2,111.98 | $2,691.00 | $3,057.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,225.05
| Facility | | $2,225.05 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $4,476.40
| Professional | | $343.68 | $2,225.05 | $4,476.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.64 / $1,509.92 / $2,761.80
| Professional | | $1,186.64 | $1,509.92 | $2,761.80 |