- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,930.75 / $1,930.75 / $1,930.75
| Facility | | $1,930.75 | $1,930.75 | $1,930.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.75 / $2,206.57 / $2,859.85
| Professional | | $1,930.75 | $2,206.57 | $2,859.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,940.31 / $3,940.31 / $3,940.31
| Professional | | $3,940.31 | $3,940.31 | $3,940.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.97 / $3,323.97 / $3,323.97
| Facility | | $3,323.97 | $3,323.97 | $3,323.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.50 / $3,323.97 / $3,323.97
| Professional | | $2,426.50 | $3,323.97 | $3,323.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,206.57 / $3,295.85 / $25,033.69
| Facility | | $2,206.57 | $3,295.85 | $25,033.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.65 / $2,966.59 / $4,450.64
| Professional | | $1,496.65 | $2,966.59 | $4,450.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.65 / $2,151.26 / $3,574.81
| Professional | | $1,496.65 | $2,151.26 | $3,574.81 |