- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,822.37 / $1,822.37 / $1,822.37
| Facility | | $1,822.37 | $1,822.37 | $1,822.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.85 / $1,822.37 / $1,960.06
| Professional | | $1,818.85 | $1,822.37 | $1,960.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.77 / $5,017.18 / $6,503.75
| Facility | | $2,463.77 | $5,017.18 | $6,503.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,415.67 / $2,653.29 / $4,548.49
| Professional | | $2,415.67 | $2,653.29 | $4,548.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $4,441.88
| Facility | | $2,677.88 | $2,677.88 | $4,441.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,677.88 / $18,249.09
| Professional | | $1,954.85 | $2,677.88 | $18,249.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.09 / $2,234.90 / $3,104.03
| Professional | | $1,854.09 | $2,234.90 | $3,104.03 |