- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,075.80 / $2,075.80 / $2,075.80
| Facility | | $2,075.80 | $2,075.80 | $2,075.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.22 / $1,930.31 / $2,075.80
| Professional | | $1,715.22 | $1,930.31 | $2,075.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,309.96 / $4,270.91 / $4,886.35
| Facility | | $3,309.96 | $4,270.91 | $4,886.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,199.78 / $2,199.78 / $2,308.42
| Professional | | $2,199.78 | $2,199.78 | $2,308.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $3,214.74
| Facility | | $3,214.74 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $3,214.74
| Professional | | $2,732.53 | $2,732.53 | $3,214.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,776.09 / $2,776.09 / $2,776.09
| Facility | | $2,776.09 | $2,776.09 | $2,776.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,776.09 / $2,883.19 / $4,270.91
| Professional | | $2,776.09 | $2,883.19 | $4,270.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.05 / $2,130.71 / $2,780.96
| Professional | | $1,626.05 | $2,130.71 | $2,780.96 |