- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,019.62 / $2,019.62 / $2,019.62
| Facility | | $2,019.62 | $2,019.62 | $2,019.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,019.62 / $2,308.14 / $2,308.14
| Professional | | $2,019.62 | $2,308.14 | $2,308.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,360.52 / $4,121.68 / $4,121.68
| Professional | | $3,360.52 | $4,121.68 | $4,121.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $2,780.72
| Facility | | $2,780.72 | $2,780.72 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $2,780.72
| Professional | | $2,029.93 | $2,780.72 | $2,780.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,433.28 / $2,827.09 / $23,421.34
| Facility | | $1,433.28 | $2,827.09 | $23,421.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.08 / $2,933.77 / $4,765.05
| Professional | | $1,480.08 | $2,933.77 | $4,765.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.08 / $2,243.61 / $3,344.31
| Professional | | $1,480.08 | $2,243.61 | $3,344.31 |