- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,208.76 / $2,208.76 / $2,208.76
| Facility | | $2,208.76 | $2,208.76 | $2,208.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.76 / $2,237.67 / $2,237.67
| Professional | | $2,208.76 | $2,237.67 | $2,237.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,838.58 / $3,356.20 / $3,439.69
| Professional | | $2,838.58 | $3,356.20 | $3,439.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,733.50 / $3,770.84 / $4,741.55
| Professional | | $3,733.50 | $3,770.84 | $4,741.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,431.90 / $2,237.67 / $15,138.02
| Facility | | $1,431.90 | $2,237.67 | $15,138.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.46 / $1,514.58 / $2,418.92
| Professional | | $1,209.46 | $1,514.58 | $2,418.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.50 / $2,414.25 / $3,993.42
| Professional | | $966.50 | $2,414.25 | $3,993.42 |