- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,241.62 / $2,241.62 / $2,241.62
| Facility | | $2,241.62 | $2,241.62 | $2,241.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.62 / $2,561.85 / $2,586.03
| Professional | | $2,241.62 | $2,561.85 | $2,586.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,112.78 / $4,574.72 / $4,574.72
| Professional | | $3,112.78 | $4,574.72 | $4,574.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $3,745.37
| Facility | | $3,745.37 | $3,745.37 | $3,745.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $6,712.13
| Professional | | $2,734.12 | $2,734.12 | $6,712.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,679.50 / $3,137.83 / $27,462.75
| Facility | | $1,679.50 | $3,137.83 | $27,462.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.35 / $3,437.75 / $5,288.82
| Professional | | $1,734.35 | $3,437.75 | $5,288.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.35 / $2,497.63 / $3,918.83
| Professional | | $1,734.35 | $2,497.63 | $3,918.83 |