- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,075.80 / $2,075.80 / $4,411.08
| Facility | | $2,075.80 | $2,075.80 | $4,411.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.40 / $1,681.40 / $1,681.40
| Professional | | $1,681.40 | $1,681.40 | $1,681.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.34 / $12.34 / $1,349.27
| Professional | | $12.34 | $12.34 | $1,349.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,385.08 / $2,981.34
| Professional | | $2,385.08 | $2,385.08 | $2,981.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.80 / $2,075.80 / $2,513.79
| Professional | | $2,075.80 | $2,075.80 | $2,513.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,075.80 / $2,075.80 / $3,362.80
| Facility | | $2,075.80 | $2,075.80 | $3,362.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.40 / $1,681.40 / $2,075.80
| Professional | | $1,681.40 | $1,681.40 | $2,075.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.48 / $1,245.48 / $3,009.91
| Professional | | $1,245.48 | $1,245.48 | $3,009.91 |