- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,477.41 / $1,477.41 / $1,477.41
| Facility | | $1,477.41 | $1,477.41 | $1,477.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.45 / $1,491.12 / $1,491.12
| Professional | | $1,357.45 | $1,491.12 | $1,491.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.68 / $2,244.91 / $2,300.75
| Professional | | $1,898.68 | $2,244.91 | $2,300.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.00 / $2,084.64 / $2,621.28
| Professional | | $2,064.00 | $2,084.64 | $2,621.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $754.10 / $1,477.41 / $8,261.60
| Facility | | $754.10 | $1,477.41 | $8,261.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.12 / $1,153.56 / $1,617.99
| Professional | | $740.12 | $1,153.56 | $1,617.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.15 / $1,281.73 / $2,207.48
| Professional | | $602.15 | $1,281.73 | $2,207.48 |