- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,370.73 / $2,370.73 / $2,370.73
| Facility | | $2,370.73 | $2,370.73 | $2,370.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,370.73 / $3,254.09 / $3,254.09
| Professional | | $2,370.73 | $3,254.09 | $3,254.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,046.75 / $3,602.33 / $3,691.94
| Professional | | $3,046.75 | $3,602.33 | $3,691.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,503.75 / $4,548.79 / $5,719.76
| Professional | | $4,503.75 | $4,548.79 | $5,719.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,736.00 / $3,181.40 / $16,910.75
| Facility | | $1,736.00 | $3,181.40 | $16,910.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.16 / $2,411.92 / $2,679.92
| Professional | | $1,298.16 | $2,411.92 | $2,679.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.97 / $2,411.92 / $2,679.92
| Professional | | $1,071.97 | $2,411.92 | $2,679.92 |