- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,387.23 / $1,387.23 / $1,387.23
| Facility | | $1,387.23 | $1,387.23 | $1,387.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.23 / $1,579.73 / $1,579.73
| Professional | | $1,387.23 | $1,579.73 | $1,579.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.80 / $2,107.90 / $2,160.33
| Professional | | $1,782.80 | $2,107.90 | $2,160.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,186.63 / $2,208.48 / $2,777.01
| Professional | | $2,186.63 | $2,208.48 | $2,777.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.13 / $1,525.39 / $8,782.71
| Facility | | $830.13 | $1,525.39 | $8,782.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.62 / $1,260.83 / $1,542.02
| Professional | | $759.62 | $1,260.83 | $1,542.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.31 / $951.25 / $1,519.23
| Professional | | $476.31 | $951.25 | $1,519.23 |