- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,716.86 / $1,716.86 / $1,716.86
| Facility | | $1,716.86 | $1,716.86 | $1,716.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.86 / $1,951.22 / $1,951.22
| Professional | | $1,716.86 | $1,951.22 | $1,951.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.41 / $2,608.76 / $2,673.65
| Professional | | $2,206.41 | $2,608.76 | $2,673.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,700.75 / $2,727.76 / $3,429.95
| Professional | | $2,700.75 | $2,727.76 | $3,429.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,025.34 / $1,823.08 / $10,007.20
| Facility | | $1,025.34 | $1,823.08 | $10,007.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.12 / $1,557.70 / $1,908.43
| Professional | | $940.12 | $1,557.70 | $1,908.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.31 / $1,557.70 / $2,329.55
| Professional | | $692.31 | $1,557.70 | $2,329.55 |