- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,867.40 / $1,867.40 / $1,867.40
| Facility | | $1,867.40 | $1,867.40 | $1,867.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.52 / $2,033.90 / $2,848.38
| Professional | | $1,825.52 | $2,033.90 | $2,848.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.07 / $3,006.81 / $5,081.54
| Facility | | $2,754.07 | $3,006.81 | $5,081.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $2,194.96 / $4,449.58
| Professional | | $2,194.96 | $2,194.96 | $4,449.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,642.37 / $4,675.02 / $6,656.82
| Professional | | $4,642.37 | $4,675.02 | $6,656.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,962.43 / $5,081.54 / $5,081.54
| Professional | | $4,962.43 | $5,081.54 | $5,081.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.16 / $2,562.76 / $5,081.54
| Professional | | $2,272.16 | $2,562.76 | $5,081.54 |