- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.69 / $2,571.69 / $2,571.69
| Facility | | $2,571.69 | $2,571.69 | $2,571.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.64 / $2,605.98 / $3,214.07
| Professional | | $2,091.64 | $2,605.98 | $3,214.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.38 / $3,187.86 / $3,825.43
| Professional | | $2,634.38 | $3,187.86 | $3,825.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $3,206.26
| Professional | | $2,271.73 | $2,672.64 | $3,206.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,346.88 / $19,176.53 / $19,377.48
| Facility | | $5,346.88 | $19,176.53 | $19,377.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.85 / $2,055.80 / $3,108.11
| Professional | | $1,364.85 | $2,055.80 | $3,108.11 |