- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,362.76 / $2,362.76 / $2,362.76
| Facility | | $2,362.76 | $2,362.76 | $2,362.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,362.76 / $2,480.56 / $2,700.30
| Professional | | $2,362.76 | $2,480.56 | $2,700.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,931.49 / $4,821.96 / $4,821.96
| Professional | | $3,931.49 | $4,821.96 | $4,821.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $3,148.57 / $3,148.57
| Professional | | $2,298.46 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,330.20 / $3,307.42 / $20,548.93
| Facility | | $1,330.20 | $3,307.42 | $20,548.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.64 / $2,722.78 / $5,377.75
| Professional | | $1,373.64 | $2,722.78 | $5,377.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.64 / $2,483.05 / $3,104.50
| Professional | | $1,373.64 | $2,483.05 | $3,104.50 |