- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,433.28 / $1,433.28 / $1,433.28
| Facility | | $1,433.28 | $1,433.28 | $1,433.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.28 / $1,641.12 / $14,614.90
| Professional | | $1,433.28 | $1,641.12 | $14,614.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $2,780.72
| Facility | | $2,780.72 | $2,780.72 | $2,780.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $3,421.16
| Professional | | $2,029.93 | $2,780.72 | $3,421.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,685.61 / $4,331.63 / $5,631.11
| Professional | | $2,685.61 | $4,331.63 | $5,631.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,195.60 / $5,794.46 / $5,794.46
| Facility | | $5,195.60 | $5,794.46 | $5,794.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,299.57 / $4,153.47 / $6,230.21
| Professional | | $3,299.57 | $4,153.47 | $6,230.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.58 / $2,220.13 / $3,185.06
| Professional | | $2,004.58 | $2,220.13 | $3,185.06 |