- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.86 / $1,949.86 / $1,949.86
| Facility | | $1,949.86 | $1,949.86 | $1,949.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.86 / $2,228.41 / $2,228.41
| Professional | | $1,949.86 | $2,228.41 | $2,228.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,707.64 / $3,979.31 / $3,979.31
| Professional | | $2,707.64 | $3,979.31 | $3,979.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $2,728.17
| Facility | | $2,728.17 | $2,728.17 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $5,087.25
| Professional | | $1,991.56 | $1,991.56 | $5,087.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.01 / $2,729.43 / $20,802.65
| Facility | | $1,277.01 | $2,729.43 | $20,802.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.72 / $2,613.91 / $4,600.46
| Professional | | $1,318.72 | $2,613.91 | $4,600.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.72 / $2,112.96 / $2,979.70
| Professional | | $1,318.72 | $2,112.96 | $2,979.70 |