- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,923.82 / $1,923.82 / $1,923.82
| Facility | | $1,923.82 | $1,923.82 | $1,923.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,923.82 / $2,367.09 / $4,392.10
| Professional | | $1,923.82 | $2,367.09 | $4,392.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $5,235.09
| Facility | | $3,745.37 | $3,745.37 | $5,235.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $6,712.13
| Professional | | $2,734.12 | $2,734.12 | $6,712.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,782.64 / $4,816.28 / $6,857.97
| Professional | | $4,782.64 | $4,816.28 | $6,857.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,112.39 / $5,235.09 / $5,235.09
| Professional | | $5,112.39 | $5,235.09 | $5,235.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,360.51 / $2,798.34 / $5,235.09
| Professional | | $2,360.51 | $2,798.34 | $5,235.09 |