- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,405.11 / $2,405.11 / $2,405.11
| Facility | | $2,405.11 | $2,405.11 | $2,405.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.30 / $1,982.30 / $2,405.11
| Professional | | $1,982.30 | $1,982.30 | $2,405.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,775.50 / $4,418.21 / $4,494.57
| Professional | | $3,775.50 | $4,418.21 | $4,494.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,832.50 / $3,870.83 / $4,867.28
| Professional | | $3,832.50 | $3,870.83 | $4,867.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,608.94 / $2,405.11 / $14,832.59
| Facility | | $1,608.94 | $2,405.11 | $14,832.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.36 / $1,623.13 / $2,334.62
| Professional | | $1,119.36 | $1,623.13 | $2,334.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.50 / $1,623.13 / $2,334.62
| Professional | | $927.50 | $1,623.13 | $2,334.62 |