- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,099.05 / $1,099.05 / $1,099.05
| Facility | | $1,099.05 | $1,099.05 | $1,099.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.05 / $1,469.98 / $1,987.95
| Professional | | $1,099.05 | $1,469.98 | $1,987.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,879.15 / $2,017.28 / $3,228.39
| Facility | | $1,879.15 | $2,017.28 | $3,228.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $1,472.61 / $2,826.89
| Professional | | $1,472.61 | $1,472.61 | $2,826.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,949.37 / $2,970.12 / $4,229.18
| Professional | | $2,949.37 | $2,970.12 | $4,229.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,152.72 / $3,228.39 / $3,228.39
| Professional | | $3,152.72 | $3,228.39 | $3,228.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.70 / $1,610.60 / $3,228.39
| Professional | | $1,455.70 | $1,610.60 | $3,228.39 |