- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,005.72 / $2,005.72 / $2,005.72
| Facility | | $2,005.72 | $2,005.72 | $2,005.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.72 / $2,690.16 / $23,957.20
| Professional | | $2,005.72 | $2,690.16 | $23,957.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.38 / $4,366.38 / $4,366.38
| Facility | | $4,366.38 | $4,366.38 | $4,366.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.46 / $4,366.38 / $4,510.25
| Professional | | $3,187.46 | $4,366.38 | $4,510.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,540.55 / $5,710.58 / $7,423.75
| Professional | | $3,540.55 | $5,710.58 | $7,423.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,849.61 / $7,639.11 / $7,639.11
| Facility | | $6,849.61 | $7,639.11 | $7,639.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,349.97 / $5,475.72 / $8,213.57
| Professional | | $4,349.97 | $5,475.72 | $8,213.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,805.20 / $3,106.84 / $4,457.16
| Professional | | $2,805.20 | $3,106.84 | $4,457.16 |