- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.55 / $2,073.55 / $2,073.55
| Facility | | $2,073.55 | $2,073.55 | $2,073.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.55 / $2,369.77 / $2,522.87
| Professional | | $2,073.55 | $2,369.77 | $2,522.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $3,578.08 / $3,578.08
| Facility | | $3,578.08 | $3,578.08 | $3,578.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $6,412.50
| Professional | | $2,612.00 | $2,612.00 | $6,412.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,556.51 / $2,902.58 / $25,854.57
| Facility | | $1,556.51 | $2,902.58 | $25,854.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.34 / $3,186.02 / $4,892.31
| Professional | | $1,607.34 | $3,186.02 | $4,892.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.34 / $2,310.37 / $3,631.86
| Professional | | $1,607.34 | $2,310.37 | $3,631.86 |