- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,442.35 / $1,442.35 / $1,442.35
| Facility | | $1,442.35 | $1,442.35 | $1,442.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.25 / $1,442.35 / $1,906.17
| Professional | | $1,436.25 | $1,442.35 | $1,906.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,965.24 / $3,970.93 / $5,147.50
| Facility | | $1,965.24 | $3,970.93 | $5,147.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.93 / $2,116.41 / $3,628.13
| Professional | | $1,911.93 | $2,116.41 | $3,628.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.78 / $1,902.78 / $3,795.00
| Facility | | $1,902.78 | $1,902.78 | $3,795.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,902.78 / $15,906.00
| Professional | | $1,389.03 | $1,902.78 | $15,906.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.45 / $2,049.89 / $2,445.75
| Professional | | $1,467.45 | $2,049.89 | $2,445.75 |