- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $3,467.37
| Facility | | $2,691.53 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,019.95 / $3,467.37
| Professional | | $2,238.72 | $3,019.95 | $3,467.37 |
- 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
- $691.83 / $5,011.87 / $9,772.37
| Facility | | $691.83 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,630.78 / $6,165.95
| Professional | | $1,230.27 | $3,630.78 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,467.37 / $6,165.95
| Professional | | $1,230.27 | $3,467.37 | $6,165.95 |