- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,985.61 / $2,985.61 / $2,985.61
| Facility | | $2,985.61 | $2,985.61 | $2,985.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,479.73 / $2,479.73 / $2,985.61
| Professional | | $2,479.73 | $2,479.73 | $2,985.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,882.58 / $4,543.51 / $4,622.04
| Professional | | $3,882.58 | $4,543.51 | $4,622.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,729.50 / $4,776.80 / $6,006.47
| Professional | | $4,729.50 | $4,776.80 | $6,006.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.73 / $2,985.61 / $19,176.53
| Facility | | $2,479.73 | $2,985.61 | $19,176.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.71 / $2,388.48 / $3,463.36
| Professional | | $1,564.71 | $2,388.48 | $3,463.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.85 / $2,388.48 / $4,589.39
| Professional | | $1,364.85 | $2,388.48 | $4,589.39 |