- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,468.25 / $2,468.25 / $2,468.25
| Facility | | $2,468.25 | $2,468.25 | $2,468.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.42 / $2,468.25 / $4,106.58
| Professional | | $2,298.42 | $2,468.25 | $4,106.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,517.45 / $5,517.45 / $6,639.70
| Professional | | $5,517.45 | $5,517.45 | $6,639.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $4,116.47
| Facility | | $3,728.42 | $3,728.42 | $4,116.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $3,647.50 / $3,728.42
| Professional | | $2,721.75 | $3,647.50 | $3,728.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,468.25 / $4,106.58 / $8,927.70
| Facility | | $2,468.25 | $4,106.58 | $8,927.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,275.58 / $4,275.58 / $4,275.58
| Professional | | $4,275.58 | $4,275.58 | $4,275.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.64 / $2,752.59 / $3,948.74
| Professional | | $2,100.64 | $2,752.59 | $3,948.74 |