- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.60 / $2,264.60 / $5,814.50
| Facility | | $2,264.60 | $2,264.60 | $5,814.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.60 / $2,975.35 / $5,814.50
| Professional | | $2,264.60 | $2,975.35 | $5,814.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,989.82 / $6,989.82 / $6,989.82
| Facility | | $6,989.82 | $6,989.82 | $6,989.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,643.96 / $3,643.96 / $7,442.79
| Professional | | $3,643.96 | $3,643.96 | $7,442.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $5,145.75
| Facility | | $4,052.23 | $4,052.23 | $5,145.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $3,998.46 / $4,619.58
| Professional | | $2,958.13 | $3,998.46 | $4,619.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,886.97 / $5,591.86 / $9,086.77
| Professional | | $3,886.97 | $5,591.86 | $9,086.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.50 / $3,713.13 / $4,641.41
| Professional | | $2,180.50 | $3,713.13 | $4,641.41 |