- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,233.76 / $2,233.76 / $2,233.76
| Facility | | $2,233.76 | $2,233.76 | $2,233.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.76 / $2,233.76 / $2,402.51
| Professional | | $2,233.76 | $2,233.76 | $2,402.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,997.28 / $3,644.30 / $6,833.07
| Facility | | $1,997.28 | $3,644.30 | $6,833.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.00 / $2,961.00 / $4,099.84
| Professional | | $1,246.00 | $2,961.00 | $4,099.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $3,600.52 / $5,214.89
| Facility | | $3,600.52 | $3,600.52 | $5,214.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,600.52 / $21,820.33
| Professional | | $3,060.44 | $3,600.52 | $21,820.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.63 / $2,823.50 / $3,787.71
| Professional | | $2,272.63 | $2,823.50 | $3,787.71 |