- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,718.86 / $1,718.86 / $1,718.86
| Facility | | $1,718.86 | $1,718.86 | $1,718.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.86 / $2,305.40 / $20,530.70
| Professional | | $1,718.86 | $2,305.40 | $20,530.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,072.36 / $4,072.36 / $4,072.36
| Facility | | $4,072.36 | $4,072.36 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $4,072.36 / $4,194.53
| Professional | | $2,972.82 | $4,072.36 | $4,194.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,415.53 / $3,896.02 / $5,064.82
| Professional | | $2,415.53 | $3,896.02 | $5,064.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,673.12 / $5,211.75 / $5,211.75
| Facility | | $4,673.12 | $5,211.75 | $5,211.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,967.75 / $3,735.78 / $5,603.67
| Professional | | $2,967.75 | $3,735.78 | $5,603.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.98 / $2,662.49 / $3,819.68
| Professional | | $2,403.98 | $2,662.49 | $3,819.68 |