- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,971.85 / $1,971.85 / $2,906.22
| Facility | | $1,971.85 | $1,971.85 | $2,906.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.82 / $1,971.85 / $1,971.85
| Professional | | $1,898.82 | $1,971.85 | $1,971.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.59 / $2,507.59 / $2,507.59
| Facility | | $2,507.59 | $2,507.59 | $2,507.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $2,507.59 / $2,507.59
| Professional | | $1,830.54 | $2,507.59 | $2,507.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.80 / $2,585.26 / $18,505.52
| Facility | | $1,137.80 | $2,585.26 | $18,505.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.96 / $1,987.72 / $4,124.51
| Professional | | $1,174.96 | $1,987.72 | $4,124.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.96 / $1,762.45 / $2,528.44
| Professional | | $1,174.96 | $1,762.45 | $2,528.44 |