- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.96 / $2,050.96 / $2,050.96
| Facility | | $2,050.96 | $2,050.96 | $2,050.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,050.96 / $2,506.83 / $2,506.83
| Professional | | $2,050.96 | $2,506.83 | $2,506.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,635.77 / $3,116.41 / $3,193.94
| Professional | | $2,635.77 | $3,116.41 | $3,193.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,469.50 / $3,504.20 / $4,406.27
| Professional | | $3,469.50 | $3,504.20 | $4,406.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,266.49 / $2,474.75 / $13,967.65
| Facility | | $1,266.49 | $2,474.75 | $13,967.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.06 / $1,998.82 / $2,620.67
| Professional | | $1,123.06 | $1,998.82 | $2,620.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.11 / $1,332.55 / $2,246.11
| Professional | | $755.11 | $1,332.55 | $2,246.11 |