- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.49 / $1,640.49 / $1,640.49
| Facility | | $1,640.49 | $1,640.49 | $1,640.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.49 / $2,097.06 / $2,651.81
| Professional | | $1,640.49 | $2,097.06 | $2,651.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $4,818.83
| Facility | | $2,756.64 | $2,756.64 | $4,818.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $5,723.63
| Professional | | $2,012.35 | $2,012.35 | $5,723.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,402.37 / $4,433.32 / $6,312.67
| Professional | | $4,402.37 | $4,433.32 | $6,312.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,705.89 / $4,818.83 / $4,818.83
| Professional | | $4,705.89 | $4,818.83 | $4,818.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,998.41 / $2,430.28 / $4,423.93
| Professional | | $1,998.41 | $2,430.28 | $4,423.93 |