- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,253.98 / $2,253.98 / $2,253.98
| Facility | | $2,253.98 | $2,253.98 | $2,253.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,253.98 / $2,575.98 / $2,600.09
| Professional | | $2,253.98 | $2,575.98 | $2,600.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,943.38 / $3,943.38 / $3,943.38
| Facility | | $3,943.38 | $3,943.38 | $3,943.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $3,943.38 / $3,943.38
| Professional | | $2,878.67 | $3,943.38 | $3,943.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,691.96 / $3,155.15 / $27,719.31
| Facility | | $1,691.96 | $3,155.15 | $27,719.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.21 / $3,463.25 / $5,318.03
| Professional | | $1,747.21 | $3,463.25 | $5,318.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.21 / $2,620.82 / $3,947.89
| Professional | | $1,747.21 | $2,620.82 | $3,947.89 |