- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,187.76
| Facility | | $1,905.46 | $1,905.46 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,137.96 / $2,570.40
| Professional | | $2,089.30 | $2,137.96 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $4,168.69
| Facility | | $2,187.76 | $2,187.76 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $11,748.98 / $11,748.98
| Professional | | $2,187.76 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $3,388.44
| Professional | | $2,137.96 | $2,290.87 | $3,388.44 |