- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,851.24 / $1,851.24 / $1,851.24
| Facility | | $1,851.24 | $1,851.24 | $1,851.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.24 / $2,478.41 / $2,478.41
| Professional | | $1,851.24 | $2,478.41 | $2,478.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,379.11 / $2,812.94 / $2,882.92
| Professional | | $2,379.11 | $2,812.94 | $2,882.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,430.50 / $3,464.81 / $4,356.74
| Professional | | $3,430.50 | $3,464.81 | $4,356.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.04 / $1,851.24 / $11,959.60
| Facility | | $1,274.04 | $1,851.24 | $11,959.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.70 / $1,710.08 / $2,057.80
| Professional | | $1,013.70 | $1,710.08 | $2,057.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.04 / $1,710.08 / $2,027.39
| Professional | | $760.04 | $1,710.08 | $2,027.39 |