- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,532.22 / $1,532.22 / $1,532.22
| Facility | | $1,532.22 | $1,532.22 | $1,532.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,532.22 / $1,741.36 / $1,741.36
| Professional | | $1,532.22 | $1,741.36 | $1,741.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.13 / $2,328.19 / $2,386.12
| Professional | | $1,969.13 | $2,328.19 | $2,386.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,410.13 / $2,434.23 / $3,060.86
| Professional | | $2,410.13 | $2,434.23 | $3,060.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.21 / $1,705.72 / $9,683.48
| Facility | | $954.21 | $1,705.72 | $9,683.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.32 / $1,390.17 / $2,598.17
| Professional | | $864.32 | $1,390.17 | $2,598.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,224.69 / $1,224.69 / $1,224.69
| Facility | | $1,224.69 | $1,224.69 | $1,224.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.85 / $1,390.17 / $2,598.17
| Professional | | $617.85 | $1,390.17 | $2,598.17 |