- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,514.08 / $1,514.08 / $1,514.08
| Facility | | $1,514.08 | $1,514.08 | $1,514.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.08 / $1,767.98 / $2,997.13
| Professional | | $1,514.08 | $1,767.98 | $2,997.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $4,027.56
| Facility | | $3,001.57 | $3,001.57 | $4,027.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $2,191.15 / $3,526.67
| Professional | | $2,191.15 | $2,191.15 | $3,526.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,679.47 / $3,705.36 / $5,276.10
| Professional | | $3,679.47 | $3,705.36 | $5,276.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,833.49 / $4,027.56 / $4,027.56
| Professional | | $3,833.49 | $4,027.56 | $4,027.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.77 / $2,009.30 / $3,697.50
| Professional | | $1,857.77 | $2,009.30 | $3,697.50 |