- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,253.45 / $3,253.45 / $3,253.45
| Facility | | $3,253.45 | $3,253.45 | $3,253.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.87 / $3,253.45 / $3,253.45
| Professional | | $2,675.87 | $3,253.45 | $3,253.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,248.01 / $2,248.01 / $2,248.01
| Facility | | $2,248.01 | $2,248.01 | $2,248.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.66 / $3,763.00 / $6,575.51
| Professional | | $2,508.66 | $3,763.00 | $6,575.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.00 / $3,416.12 / $8,753.15
| Facility | | $1,481.00 | $3,416.12 | $8,753.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.72 / $3,165.40 / $5,851.58
| Professional | | $1,844.72 | $3,165.40 | $5,851.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.00 / $5,524.00 / $9,232.95
| Facility | | $1,481.00 | $5,524.00 | $9,232.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.66 / $2,938.85 / $4,604.49
| Professional | | $1,969.66 | $2,938.85 | $4,604.49 |