- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,305.40 / $2,305.40 / $5,919.28
| Facility | | $2,305.40 | $2,305.40 | $5,919.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,305.40 / $2,948.49 / $5,919.28
| Professional | | $2,305.40 | $2,948.49 | $5,919.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,115.78 / $7,115.78 / $7,115.78
| Facility | | $7,115.78 | $7,115.78 | $7,115.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,205.32 / $3,205.32 / $7,115.78
| Professional | | $3,205.32 | $3,205.32 | $7,115.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $5,238.47
| Facility | | $4,072.36 | $4,072.36 | $5,238.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $4,072.36 / $4,702.83
| Professional | | $2,972.82 | $4,072.36 | $4,702.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,957.00 / $5,692.62 / $9,250.51
| Professional | | $3,957.00 | $5,692.62 | $9,250.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.69 / $2,662.49 / $4,437.47
| Professional | | $2,084.69 | $2,662.49 | $4,437.47 |