- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,449.67 / $1,449.67 / $1,449.67
| Facility | | $1,449.67 | $1,449.67 | $1,449.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.67 / $1,761.66 / $2,515.69
| Professional | | $1,449.67 | $1,761.66 | $2,515.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,481.10 / $3,944.84
| Facility | | $2,481.10 | $2,481.10 | $3,944.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.20 / $1,811.20 / $3,454.24
| Professional | | $1,811.20 | $1,811.20 | $3,454.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,603.90 / $3,629.25 / $5,167.74
| Professional | | $3,603.90 | $3,629.25 | $5,167.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,754.76 / $3,944.84 / $3,944.84
| Professional | | $3,754.76 | $3,944.84 | $3,944.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,600.65 / $2,964.57 / $3,944.84
| Facility | | $2,600.65 | $2,964.57 | $3,944.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.74 / $2,047.30 / $3,944.84
| Professional | | $1,778.74 | $2,047.30 | $3,944.84 |