- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.93 / $1,080.93 / $1,080.93
| Facility | | $1,080.93 | $1,080.93 | $1,080.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.93 / $1,304.09 / $2,283.71
| Professional | | $1,080.93 | $1,304.09 | $2,283.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,683.52 / $1,902.78 / $2,941.43
| Facility | | $1,683.52 | $1,902.78 | $2,941.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,389.03 / $2,575.62
| Professional | | $1,389.03 | $1,389.03 | $2,575.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,687.22 / $2,706.12 / $3,853.27
| Professional | | $2,687.22 | $2,706.12 | $3,853.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,799.70 / $2,941.43 / $2,941.43
| Professional | | $2,799.70 | $2,941.43 | $2,941.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.30 / $1,467.45 / $2,700.38
| Professional | | $1,326.30 | $1,467.45 | $2,700.38 |