- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,243.60 / $2,243.60 / $2,243.60
| Facility | | $2,243.60 | $2,243.60 | $2,243.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.60 / $2,564.12 / $2,564.12
| Professional | | $2,243.60 | $2,564.12 | $2,564.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,670.30 / $3,670.30 / $3,670.30
| Facility | | $3,670.30 | $3,670.30 | $3,670.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $3,670.30 / $3,670.30
| Professional | | $2,679.32 | $3,670.30 | $3,670.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.53 / $3,140.62 / $24,492.50
| Facility | | $1,476.53 | $3,140.62 | $24,492.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,524.75 / $3,022.30 / $5,293.51
| Professional | | $1,524.75 | $3,022.30 | $5,293.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.16 / $2,492.44 / $3,445.23
| Professional | | $1,739.16 | $2,492.44 | $3,445.23 |