- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,681.92 / $1,681.92 / $1,681.92
| Facility | | $1,681.92 | $1,681.92 | $1,681.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.92 / $2,003.88 / $3,138.73
| Professional | | $1,681.92 | $2,003.88 | $3,138.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,703.99 / $3,532.34 / $4,576.82
| Facility | | $2,703.99 | $3,532.34 | $4,576.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.61 / $2,578.61 / $4,007.62
| Professional | | $2,578.61 | $2,578.61 | $4,007.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,181.26 / $4,210.67 / $5,995.63
| Professional | | $4,181.26 | $4,210.67 | $5,995.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,356.29 / $4,576.82 / $4,576.82
| Professional | | $4,356.29 | $4,576.82 | $4,576.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,050.06 / $3,050.06 / $3,050.06
| Facility | | $3,050.06 | $3,050.06 | $3,050.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,063.71 / $2,613.77 / $4,576.82
| Professional | | $2,063.71 | $2,613.77 | $4,576.82 |