- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,467.37
| Facility | | $2,691.53 | $2,691.53 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,090.30 / $3,467.37
| Professional | | $1,380.38 | $3,090.30 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,981.07 / $4,073.80
| Professional | | $3,019.95 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,248.07
| Professional | | $4,265.80 | $4,265.80 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,162.28 / $7,943.28
| Facility | | $2,691.53 | $3,162.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $5,495.41
| Professional | | $1,819.70 | $2,754.23 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,388.44 / $5,495.41
| Professional | | $1,819.70 | $3,388.44 | $5,495.41 |