- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,939.13 / $1,939.13 / $1,939.13
| Facility | | $1,939.13 | $1,939.13 | $1,939.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.59 / $1,697.59 / $1,939.13
| Professional | | $1,697.59 | $1,697.59 | $1,939.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.06 / $2,946.49 / $3,019.78
| Professional | | $2,492.06 | $2,946.49 | $3,019.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,832.38 / $2,860.70 / $3,597.12
| Professional | | $2,832.38 | $2,860.70 | $3,597.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.03 / $1,939.13 / $12,090.55
| Facility | | $1,154.03 | $1,939.13 | $12,090.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.74 / $1,266.82 / $2,123.64
| Professional | | $1,015.74 | $1,266.82 | $2,123.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.72 / $1,266.82 / $2,123.64
| Professional | | $760.72 | $1,266.82 | $2,123.64 |