- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.34 / $2,398.34 / $2,398.34
| Facility | | $2,398.34 | $2,398.34 | $2,398.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.69 / $2,310.00 / $2,450.00
| Professional | | $1,865.69 | $2,310.00 | $2,450.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,096.62 / $3,096.62 / $3,096.62
| Facility | | $3,096.62 | $3,096.62 | $3,096.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,596.29 / $3,453.93 / $12,745.67
| Professional | | $2,596.29 | $3,453.93 | $12,745.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.24 / $2,350.00 / $4,250.85
| Professional | | $1,972.24 | $2,350.00 | $4,250.85 |