- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,461.80 / $2,461.80 / $2,461.80
| Facility | | $2,461.80 | $2,461.80 | $2,461.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,461.80 / $3,075.58 / $3,075.58
| Professional | | $2,461.80 | $3,075.58 | $3,075.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,163.75 / $3,740.67 / $3,833.72
| Professional | | $3,163.75 | $3,740.67 | $3,833.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,257.00 / $4,299.57 / $5,406.39
| Professional | | $4,257.00 | $4,299.57 | $5,406.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,886.49 / $2,713.07 / $16,837.56
| Facility | | $1,886.49 | $2,713.07 | $16,837.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.02 / $2,532.13 / $2,813.48
| Professional | | $1,348.02 | $2,532.13 | $2,813.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,413.91 / $5,413.91 / $5,413.91
| Facility | | $5,413.91 | $5,413.91 | $5,413.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.76 / $1,688.09 / $2,813.48
| Professional | | $1,321.76 | $1,688.09 | $2,813.48 |