- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,822.47 / $1,822.47 / $1,822.47
| Facility | | $1,822.47 | $1,822.47 | $1,822.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.44 / $1,513.44 / $1,822.47
| Professional | | $1,513.44 | $1,513.44 | $1,822.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.19 / $2,719.84 / $2,766.85
| Professional | | $2,324.19 | $2,719.84 | $2,766.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.25 / $2,859.56 / $3,595.69
| Professional | | $2,831.25 | $2,859.56 | $3,595.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.44 / $1,882.45 / $11,540.27
| Facility | | $1,513.44 | $1,882.45 | $11,540.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.41 / $1,533.37 / $2,300.06
| Professional | | $1,041.41 | $1,533.37 | $2,300.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.84 / $1,131.32 / $1,508.42
| Facility | | $150.84 | $1,131.32 | $1,508.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.25 / $1,419.05 / $2,300.06
| Professional | | $689.25 | $1,419.05 | $2,300.06 |