- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,177.52 / $2,177.52 / $2,177.52
| Facility | | $2,177.52 | $2,177.52 | $2,177.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.61 / $2,177.52 / $2,177.52
| Professional | | $1,701.61 | $2,177.52 | $2,177.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,382.04 / $4,476.22 / $4,973.59
| Professional | | $3,382.04 | $4,476.22 | $4,973.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,589.29 / $3,774.58 / $4,067.25
| Facility | | $1,589.29 | $3,774.58 | $4,067.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.91 / $3,863.87 / $4,067.25
| Professional | | $1,626.91 | $3,863.87 | $4,067.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,134.13 / $3,214.74 / $3,214.74
| Facility | | $3,134.13 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,355.32 / $3,060.67 / $3,214.74
| Professional | | $2,355.32 | $3,060.67 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.11 / $1,954.48 / $2,780.96
| Professional | | $1,203.11 | $1,954.48 | $2,780.96 |