- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.46 / $2,162.46 / $2,162.46
| Facility | | $2,162.46 | $2,162.46 | $2,162.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,162.46 / $5,620.35
| Professional | | $2,100.00 | $2,162.46 | $5,620.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,907.59 / $5,369.27 / $6,350.46
| Professional | | $4,907.59 | $5,369.27 | $6,350.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,054.34 / $5,612.75 / $7,248.05
| Professional | | $3,054.34 | $5,612.75 | $7,248.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.46 / $2,398.46 / $6,487.41
| Facility | | $2,162.46 | $2,398.46 | $6,487.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,336.44 / $4,010.61 / $5,477.82
| Professional | | $2,336.44 | $4,010.61 | $5,477.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,336.44 / $4,271.72 / $5,477.82
| Professional | | $2,336.44 | $4,271.72 | $5,477.82 |