- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,457.71 / $1,457.71 / $1,457.71
| Facility | | $1,457.71 | $1,457.71 | $1,457.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.71 / $1,783.36 / $2,699.73
| Professional | | $1,457.71 | $1,783.36 | $2,699.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,309.80 / $2,728.17 / $3,966.74
| Facility | | $2,309.80 | $2,728.17 | $3,966.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $5,087.25
| Professional | | $1,991.56 | $1,991.56 | $5,087.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,623.89 / $3,649.40 / $5,196.43
| Professional | | $3,623.89 | $3,649.40 | $5,196.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,473.41 / $3,966.74 / $3,966.74
| Professional | | $3,473.41 | $3,966.74 | $3,966.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.65 / $2,141.53 / $3,966.74
| Professional | | $1,800.65 | $2,141.53 | $3,966.74 |