- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,941.31 / $1,941.31 / $1,941.31
| Facility | | $1,941.31 | $1,941.31 | $1,941.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,924.20 / $1,941.31 / $2,110.21
| Professional | | $1,924.20 | $1,941.31 | $2,110.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,071.84 / $5,860.30 / $7,126.18
| Facility | | $3,071.84 | $5,860.30 | $7,126.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,573.34 / $3,308.13 / $5,671.08
| Professional | | $2,573.34 | $3,308.13 | $5,671.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $5,538.17
| Facility | | $3,001.57 | $3,001.57 | $5,538.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $3,001.57 / $21,719.88
| Professional | | $2,191.15 | $3,001.57 | $21,719.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.10 / $2,975.87 / $3,291.83
| Professional | | $1,975.10 | $2,975.87 | $3,291.83 |