- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,785.13 / $1,785.13 / $1,785.13
| Facility | | $1,785.13 | $1,785.13 | $1,785.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.13 / $2,513.48 / $2,513.48
| Professional | | $1,785.13 | $2,513.48 | $2,513.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.15 / $2,712.50 / $2,779.97
| Professional | | $2,294.15 | $2,712.50 | $2,779.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,478.88 / $3,513.66 / $4,418.17
| Professional | | $3,478.88 | $3,513.66 | $4,418.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,209.22 / $2,190.48 / $12,107.67
| Facility | | $1,209.22 | $2,190.48 | $12,107.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.50 / $1,706.20 / $1,984.31
| Professional | | $977.50 | $1,706.20 | $1,984.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.31 / $1,706.20 / $2,706.02
| Professional | | $758.31 | $1,706.20 | $2,706.02 |