- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,720.38 / $1,720.38 / $1,720.38
| Facility | | $1,720.38 | $1,720.38 | $1,720.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,720.38 / $1,883.80 / $3,137.56
| Professional | | $1,720.38 | $1,883.80 | $3,137.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,220.20 / $3,249.00 / $4,681.47
| Facility | | $3,220.20 | $3,249.00 | $4,681.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.77 / $2,371.77 / $4,099.27
| Professional | | $2,371.77 | $2,371.77 | $4,099.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,276.87 / $4,306.96 / $6,132.74
| Professional | | $4,276.87 | $4,306.96 | $6,132.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,571.76 / $4,681.47 / $4,681.47
| Professional | | $4,571.76 | $4,681.47 | $4,681.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.75 / $2,673.55 / $4,681.47
| Professional | | $2,102.75 | $2,673.55 | $4,681.47 |