- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,684.72 / $1,684.72 / $1,684.72
| Facility | | $1,684.72 | $1,684.72 | $1,684.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.72 / $2,047.29 / $3,334.09
| Professional | | $1,684.72 | $2,047.29 | $3,334.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,683.30 / $3,670.30 / $4,584.43
| Facility | | $2,683.30 | $3,670.30 | $4,584.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $2,679.32 / $4,014.29
| Professional | | $2,679.32 | $2,679.32 | $4,014.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,188.22 / $4,217.68 / $6,005.62
| Professional | | $4,188.22 | $4,217.68 | $6,005.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,363.53 / $4,584.43 / $4,584.43
| Professional | | $4,363.53 | $4,584.43 | $4,584.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.14 / $2,312.06 / $3,811.87
| Professional | | $2,067.14 | $2,312.06 | $3,811.87 |