- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $5,128.61
| Professional | | $2,238.72 | $3,090.30 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,606.93
| Facility | | $6,309.57 | $6,309.57 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $4,073.80
| Professional | | $3,548.13 | $3,548.13 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $5,128.61
| Facility | | $2,754.23 | $3,715.35 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,715.35
| Professional | | $2,691.53 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,309.57 / $6,309.57
| Professional | | $5,370.32 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $3,801.89
| Facility | | $1,949.84 | $3,388.44 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,890.45 / $5,248.07
| Professional | | $2,344.23 | $3,890.45 | $5,248.07 |