- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,684.09 / $2,684.09 / $2,684.09
| Facility | | $2,684.09 | $2,684.09 | $2,684.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,499.40 / $2,684.09 / $4,465.68
| Professional | | $2,499.40 | $2,684.09 | $4,465.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,999.92 / $5,999.92 / $7,220.30
| Professional | | $5,999.92 | $5,999.92 | $7,220.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.97 / $3,323.97 / $3,669.94
| Facility | | $3,323.97 | $3,323.97 | $3,669.94 |
- 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
- $2,684.09 / $3,997.57 / $9,575.04
| Facility | | $2,684.09 | $3,997.57 | $9,575.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,766.41 / $4,766.41 / $4,766.41
| Professional | | $4,766.41 | $4,766.41 | $4,766.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.81 / $2,966.60 / $3,825.05
| Professional | | $1,870.81 | $2,966.60 | $3,825.05 |