- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,843.10 / $2,843.10 / $2,843.10
| Facility | | $2,843.10 | $2,843.10 | $2,843.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,312.39 / $2,881.01 / $3,553.33
| Professional | | $2,312.39 | $2,881.01 | $3,553.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,053.45 / $3,698.66 / $4,438.39
| Professional | | $3,053.45 | $3,698.66 | $4,438.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,244.00
| Facility | | $2,200.00 | $2,200.00 | $2,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.00 / $2,200.00 / $2,244.00
| Professional | | $1,870.00 | $2,200.00 | $2,244.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,512.66 / $24,693.27 / $25,593.57
| Facility | | $4,512.66 | $24,693.27 | $25,593.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.92 / $2,550.96 / $3,629.57
| Professional | | $1,508.92 | $2,550.96 | $3,629.57 |