- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,029.53 / $2,029.53 / $2,029.53
| Facility | | $2,029.53 | $2,029.53 | $2,029.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.53 / $2,758.78 / $2,758.78
| Professional | | $2,029.53 | $2,758.78 | $2,758.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.23 / $3,083.85 / $3,160.57
| Professional | | $2,608.23 | $3,083.85 | $3,160.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,818.25 / $3,856.43 / $4,849.18
| Professional | | $3,818.25 | $3,856.43 | $4,849.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.77 / $2,587.27 / $14,630.94
| Facility | | $1,493.77 | $2,587.27 | $14,630.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.32 / $2,087.51 / $2,319.46
| Professional | | $1,111.32 | $2,087.51 | $2,319.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.78 / $2,087.51 / $2,319.46
| Professional | | $927.78 | $2,087.51 | $2,319.46 |