- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,797.85 / $1,797.85 / $1,797.85
| Facility | | $1,797.85 | $1,797.85 | $1,797.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.85 / $2,264.60 / $20,167.30
| Professional | | $1,797.85 | $2,264.60 | $20,167.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $4,052.23
| Facility | | $4,052.23 | $4,052.23 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $4,052.23 / $4,173.80
| Professional | | $2,958.13 | $4,052.23 | $4,173.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,043.43 / $4,908.77 / $6,381.40
| Professional | | $3,043.43 | $4,908.77 | $6,381.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,887.87 / $6,566.51 / $6,566.51
| Facility | | $5,887.87 | $6,566.51 | $6,566.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.21 / $4,706.88 / $7,060.32
| Professional | | $3,739.21 | $4,706.88 | $7,060.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.82 / $2,784.85 / $3,985.23
| Professional | | $2,574.82 | $2,784.85 | $3,985.23 |