- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,701.28 / $1,701.28 / $1,701.28
| Facility | | $1,701.28 | $1,701.28 | $1,701.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.28 / $1,935.78 / $1,944.32
| Professional | | $1,701.28 | $1,935.78 | $1,944.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,362.46 / $3,472.00 / $3,472.00
| Professional | | $2,362.46 | $3,472.00 | $3,472.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.34 / $2,561.34 / $2,561.34
| Facility | | $2,561.34 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $2,561.34 / $2,561.34
| Professional | | $1,869.78 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.06 / $2,381.46 / $16,910.75
| Facility | | $1,038.06 | $2,381.46 | $16,910.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.97 / $2,124.81 / $4,013.98
| Professional | | $1,071.97 | $2,124.81 | $4,013.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.97 / $1,787.89 / $2,422.15
| Professional | | $1,071.97 | $1,787.89 | $2,422.15 |