- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,253.22 / $3,253.22 / $3,444.68
| Facility | | $3,253.22 | $3,253.22 | $3,444.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,609.16 / $3,068.73 / $3,851.12
| Professional | | $2,609.16 | $3,068.73 | $3,851.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,281.80 / $6,260.78 / $6,260.78
| Facility | | $5,281.80 | $6,260.78 | $6,260.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,206.14 / $3,766.34 / $3,893.06
| Professional | | $3,206.14 | $3,766.34 | $3,893.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.13 / $3,248.38 / $4,849.22
| Professional | | $453.13 | $3,248.38 | $4,849.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.65 / $2,659.92 / $4,327.10
| Professional | | $2,004.65 | $2,659.92 | $4,327.10 |