- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,488.51 / $1,488.51 / $1,488.51
| Facility | | $1,488.51 | $1,488.51 | $1,488.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.68 / $1,488.51 / $2,476.53
| Professional | | $1,403.68 | $1,488.51 | $2,476.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.00 / $2,426.92 / $3,527.02
| Professional | | $1,925.00 | $2,426.92 | $3,527.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.90 / $2,425.11 / $2,677.51
| Facility | | $1,481.90 | $2,425.11 | $2,677.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,000.95 / $2,425.11
| Professional | | $1,770.33 | $2,000.95 | $2,425.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,480.67 / $2,384.00 / $5,225.63
| Facility | | $1,480.67 | $2,384.00 | $5,225.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.00 / $1,871.00 / $2,011.00
| Professional | | $1,871.00 | $1,871.00 | $2,011.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.42 / $2,248.42 / $2,248.42
| Professional | | $2,248.42 | $2,248.42 | $2,248.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.49 / $1,645.19 / $2,373.58
| Professional | | $1,233.49 | $1,645.19 | $2,373.58 |