- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.21 / $1,770.21 / $1,770.21
| Facility | | $1,770.21 | $1,770.21 | $1,770.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.21 / $2,151.19 / $3,131.90
| Professional | | $1,770.21 | $2,151.19 | $3,131.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $4,817.09
| Facility | | $2,801.20 | $2,801.20 | $4,817.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $5,721.75
| Professional | | $2,044.88 | $2,044.88 | $5,721.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,400.76 / $4,431.72 / $6,310.39
| Professional | | $4,400.76 | $4,431.72 | $6,310.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,584.97 / $4,817.09 / $4,817.09
| Professional | | $4,584.97 | $4,817.09 | $4,817.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,172.04 / $2,534.05 / $4,817.09
| Professional | | $2,172.04 | $2,534.05 | $4,817.09 |