- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $4,073.80
| Professional | | $1,778.28 | $2,454.71 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,548.13 / $4,677.35
| Facility | | $2,691.53 | $3,548.13 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,548.13
| Professional | | $2,570.40 | $2,570.40 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,897.79 / $6,760.83
| Professional | | $3,019.95 | $4,897.79 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Professional | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,890.45 / $5,248.07
| Facility | | $3,019.95 | $3,890.45 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $3,801.89
| Professional | | $2,041.74 | $2,398.83 | $3,801.89 |