- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.20 / $1,440.20 / $1,440.20
| Facility | | $1,440.20 | $1,440.20 | $1,440.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.20 / $1,931.67 / $17,202.40
| Professional | | $1,440.20 | $1,931.67 | $17,202.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $3,813.78
| Facility | | $3,813.78 | $3,813.78 | $3,813.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $3,813.78 / $3,928.19
| Professional | | $2,784.06 | $3,813.78 | $3,928.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,162.62 / $3,488.10 / $4,534.53
| Professional | | $2,162.62 | $3,488.10 | $4,534.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,183.83 / $4,666.06 / $4,666.06
| Facility | | $4,183.83 | $4,666.06 | $4,666.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,657.02 / $3,344.64 / $5,016.95
| Professional | | $2,657.02 | $3,344.64 | $5,016.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.27 / $2,230.86 / $3,200.45
| Professional | | $2,014.27 | $2,230.86 | $3,200.45 |