- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.42 / $1,526.42 / $1,526.42
| Facility | | $1,526.42 | $1,526.42 | $1,526.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.42 / $1,878.12 / $3,034.91
| Professional | | $1,526.42 | $1,878.12 | $3,034.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.04 / $2,550.04 / $4,153.68
| Facility | | $2,550.04 | $2,550.04 | $4,153.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $1,861.53 / $3,637.11
| Professional | | $1,861.53 | $1,861.53 | $3,637.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,794.69 / $3,821.39 / $5,441.32
| Professional | | $3,794.69 | $3,821.39 | $5,441.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,953.54 / $4,153.68 / $4,153.68
| Professional | | $3,953.54 | $4,153.68 | $4,153.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,625.10 / $5,441.30 / $6,529.56
| Facility | | $4,625.10 | $5,441.30 | $6,529.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,872.91 / $2,168.12 / $4,153.68
| Professional | | $1,872.91 | $2,168.12 | $4,153.68 |