- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.66 / $1,202.66 / $1,202.66
| Facility | | $1,202.66 | $1,202.66 | $1,202.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.66 / $1,677.67 / $2,121.78
| Professional | | $1,202.66 | $1,677.67 | $2,121.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,053.61 / $2,507.59 / $3,532.74
| Facility | | $2,053.61 | $2,507.59 | $3,532.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $1,830.54 / $3,093.39
| Professional | | $1,830.54 | $1,830.54 | $3,093.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,227.42 / $3,250.12 / $4,627.89
| Professional | | $3,227.42 | $3,250.12 | $4,627.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,093.39 / $3,449.94 / $3,532.74
| Professional | | $3,093.39 | $3,449.94 | $3,532.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.93 / $1,762.45 / $3,532.74
| Professional | | $1,592.93 | $1,762.45 | $3,532.74 |