- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,203.60 / $1,203.60 / $1,203.60
| Facility | | $1,203.60 | $1,203.60 | $1,203.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.60 / $1,341.15 / $1,758.45
| Professional | | $1,203.60 | $1,341.15 | $1,758.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,373.71 / $2,373.71 / $3,275.24
| Facility | | $2,373.71 | $2,373.71 | $3,275.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,017.65 / $2,867.92
| Professional | | $2,017.65 | $2,017.65 | $2,867.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,992.17 / $3,013.22 / $4,290.56
| Professional | | $2,992.17 | $3,013.22 | $4,290.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.00 / $1,641.00 / $2,189.00
| Facility | | $1,080.00 | $1,641.00 | $2,189.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.23 / $1,515.23 / $2,178.64
| Professional | | $1,515.23 | $1,515.23 | $2,178.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.58 / $1,722.96 / $3,006.83
| Professional | | $1,470.58 | $1,722.96 | $3,006.83 |