- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Facility | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $3,961.81
| Professional | | $2,326.37 | $2,326.37 | $3,961.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $702.39 / $852.39 / $1,146.73
| Facility | | $702.39 | $852.39 | $1,146.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.76 / $2,280.76 / $2,280.76
| Professional | | $2,280.76 | $2,280.76 | $2,280.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Facility | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,021.99 / $2,554.44 / $2,554.44
| Professional | | $2,021.99 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.17 / $2,654.57 / $2,736.91
| Professional | | $2,349.17 | $2,654.57 | $2,736.91 |