- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,455.41 / $2,455.41 / $2,455.41
| Facility | | $2,455.41 | $2,455.41 | $2,455.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,455.41 / $2,806.19 / $2,806.19
| Professional | | $2,455.41 | $2,806.19 | $2,806.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $3,728.42
| Facility | | $3,728.42 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $3,728.42 / $3,728.42
| Professional | | $2,721.75 | $3,728.42 | $3,728.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,806.19 / $3,762.02 / $26,807.65
| Facility | | $2,806.19 | $3,762.02 | $26,807.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.34 / $3,386.19 / $5,793.26
| Professional | | $1,708.34 | $3,386.19 | $5,793.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.34 / $2,727.73 / $3,856.19
| Professional | | $1,708.34 | $2,727.73 | $3,856.19 |