- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,905.46 / $3,090.30
| Professional | | $1,380.38 | $1,905.46 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,511.89 / $3,630.78
| Facility | | $2,041.74 | $2,511.89 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,511.89
| Professional | | $1,819.70 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,801.89 / $5,248.07
| Professional | | $2,344.23 | $3,801.89 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,754.23 / $4,073.80
| Facility | | $1,318.26 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $2,951.21
| Professional | | $1,584.89 | $1,819.70 | $2,951.21 |