- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,410.77 / $2,410.77 / $2,410.77
| Facility | | $2,410.77 | $2,410.77 | $2,410.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,410.77 / $2,530.96 / $2,755.16
| Professional | | $2,410.77 | $2,530.96 | $2,755.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,011.36 / $4,919.93 / $4,919.93
| Professional | | $4,011.36 | $4,919.93 | $4,919.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,741.63 / $2,741.63
| Professional | | $2,001.39 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.23 / $3,374.61 / $21,030.00
| Facility | | $1,357.23 | $3,374.61 | $21,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.55 / $2,778.10 / $5,487.00
| Professional | | $1,401.55 | $2,778.10 | $5,487.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.55 / $2,612.44 / $3,167.57
| Professional | | $1,401.55 | $2,612.44 | $3,167.57 |