- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.34 / $1,787.34 / $1,787.34
| Facility | | $1,787.34 | $1,787.34 | $1,787.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.34 / $2,538.80 / $2,538.80
| Professional | | $1,787.34 | $2,538.80 | $2,538.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.98 / $2,715.85 / $2,783.41
| Professional | | $2,296.98 | $2,715.85 | $2,783.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,513.75 / $3,548.89 / $4,462.46
| Professional | | $3,513.75 | $3,548.89 | $4,462.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,169.89 / $2,150.34 / $12,853.25
| Facility | | $1,169.89 | $2,150.34 | $12,853.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.71 / $1,838.40 / $2,042.67
| Professional | | $978.71 | $1,838.40 | $2,042.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.64 / $1,943.80 / $3,182.60
| Professional | | $959.64 | $1,943.80 | $3,182.60 |