- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,128.51 / $1,128.51 / $1,128.51
| Facility | | $1,128.51 | $1,128.51 | $1,128.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.51 / $1,371.38 / $2,128.21
| Professional | | $1,128.51 | $1,371.38 | $2,128.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,765.18 / $2,571.77 / $3,070.90
| Facility | | $1,765.18 | $2,571.77 | $3,070.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $1,877.39 / $2,688.98
| Professional | | $1,877.39 | $1,877.39 | $2,688.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,805.49 / $2,825.23 / $4,022.88
| Professional | | $2,805.49 | $2,825.23 | $4,022.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,998.92 / $3,070.90 / $3,070.90
| Professional | | $2,998.92 | $3,070.90 | $3,070.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.68 / $1,842.54 / $2,819.24
| Professional | | $1,384.68 | $1,842.54 | $2,819.24 |