- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.13 / $2,017.13 / $2,017.13
| Facility | | $2,017.13 | $2,017.13 | $2,017.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.13 / $2,305.29 / $2,326.86
| Professional | | $2,017.13 | $2,305.29 | $2,326.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.08 / $3,798.08 / $3,798.08
| Facility | | $3,798.08 | $3,798.08 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $3,798.08 / $3,798.08
| Professional | | $2,772.60 | $3,798.08 | $3,798.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,514.15 / $2,823.59 / $24,802.46
| Facility | | $1,514.15 | $2,823.59 | $24,802.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.60 / $3,099.31 / $4,759.17
| Professional | | $1,563.60 | $3,099.31 | $4,759.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.60 / $2,247.50 / $3,533.03
| Professional | | $1,563.60 | $2,247.50 | $3,533.03 |