- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.85 / $1,117.85 / $1,117.85
| Facility | | $1,117.85 | $1,117.85 | $1,117.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.85 / $1,323.77 / $2,016.01
| Professional | | $1,117.85 | $1,323.77 | $2,016.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,712.20 / $1,743.07 / $3,041.90
| Facility | | $1,712.20 | $1,743.07 | $3,041.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $3,818.25
| Professional | | $1,272.44 | $1,272.44 | $3,818.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,779.01 / $2,798.55 / $3,984.89
| Professional | | $2,779.01 | $2,798.55 | $3,984.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,970.61 / $3,041.90 / $3,041.90
| Professional | | $2,970.61 | $3,041.90 | $3,041.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.61 / $1,626.02 / $2,792.62
| Professional | | $1,371.61 | $1,626.02 | $2,792.62 |