- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,781.40 / $2,781.40 / $2,781.40
| Facility | | $2,781.40 | $2,781.40 | $2,781.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,781.40 / $4,269.50 / $4,269.50
| Professional | | $2,781.40 | $4,269.50 | $4,269.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,574.49 / $4,226.31 / $4,331.43
| Professional | | $3,574.49 | $4,226.31 | $4,331.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,909.25 / $5,968.34 / $7,504.75
| Professional | | $5,909.25 | $5,968.34 | $7,504.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,673.77 / $3,773.81 / $19,929.31
| Facility | | $1,673.77 | $3,773.81 | $19,929.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.03 / $2,860.87 / $3,178.74
| Professional | | $1,523.03 | $2,860.87 | $3,178.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.50 / $2,860.87 / $4,537.32
| Professional | | $1,271.50 | $2,860.87 | $4,537.32 |