- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,009.70 / $2,009.70 / $5,167.80
| Facility | | $2,009.70 | $2,009.70 | $5,167.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.70 / $2,698.74 / $2,698.74
| Professional | | $2,009.70 | $2,698.74 | $2,698.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,321.57 / $5,785.07 / $6,459.75
| Professional | | $4,321.57 | $5,785.07 | $6,459.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,299.04 / $3,299.04 / $4,843.14
| Professional | | $3,299.04 | $3,299.04 | $4,843.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,607.76 / $2,067.12 / $5,167.80
| Facility | | $1,607.76 | $2,067.12 | $5,167.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.66 / $2,658.48 / $5,742.00
| Professional | | $1,084.66 | $2,658.48 | $5,742.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.66 / $2,928.42 / $4,880.70
| Professional | | $1,084.66 | $2,928.42 | $4,880.70 |