- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,803.21 / $1,803.21 / $1,803.21
| Facility | | $1,803.21 | $1,803.21 | $1,803.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.25 / $1,803.21 / $1,939.44
| Professional | | $1,770.25 | $1,803.21 | $1,939.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,509.69 / $5,341.99 / $6,619.23
| Facility | | $2,509.69 | $5,341.99 | $6,619.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.28 / $2,702.76 / $4,633.30
| Professional | | $2,390.28 | $2,702.76 | $4,633.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,141.52 / $4,659.83
| Facility | | $3,141.52 | $3,141.52 | $4,659.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $3,141.52 / $19,530.78
| Professional | | $2,293.31 | $3,141.52 | $19,530.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.97 / $2,401.17 / $3,057.65
| Professional | | $1,719.97 | $2,401.17 | $3,057.65 |