- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,892.51 / $1,892.51 / $1,892.51
| Facility | | $1,892.51 | $1,892.51 | $1,892.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.09 / $1,892.51 / $2,035.49
| Professional | | $1,858.09 | $1,892.51 | $2,035.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,748.22 / $5,707.84 / $6,947.06
| Facility | | $2,748.22 | $5,707.84 | $6,947.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.66 / $2,959.62 / $5,073.64
| Professional | | $2,508.66 | $2,959.62 | $5,073.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $4,954.72
| Facility | | $3,297.39 | $3,297.39 | $4,954.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $3,297.39 / $20,525.49
| Professional | | $2,407.09 | $3,297.39 | $20,525.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.26 / $2,578.78 / $3,209.08
| Professional | | $1,885.26 | $2,578.78 | $3,209.08 |