- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $1,737.80
| Facility | | $1,513.56 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,737.80
| Professional | | $933.25 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,630.27 / $2,884.03
| Professional | | $1,995.26 | $2,630.27 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,862.09 / $10,471.29
| Facility | | $933.25 | $1,862.09 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $2,398.83
| Professional | | $912.01 | $1,096.48 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,235.94 / $3,235.94
| Facility | | $1,000.00 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,174.90 / $2,454.71
| Professional | | $776.25 | $1,174.90 | $2,454.71 |