- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.76 / $1,167.76 / $1,167.76
| Facility | | $1,167.76 | $1,167.76 | $1,167.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.76 / $1,323.56 / $1,938.52
| Professional | | $1,167.76 | $1,323.56 | $1,938.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,975.67 / $2,050.41 / $3,177.69
| Facility | | $1,975.67 | $2,050.41 | $3,177.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $3,373.13
| Professional | | $1,496.80 | $1,496.80 | $3,373.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,903.06 / $2,923.47 / $4,162.77
| Professional | | $2,903.06 | $2,923.47 | $4,162.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,024.57 / $3,177.69 / $3,177.69
| Professional | | $3,024.57 | $3,177.69 | $3,177.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.78 / $1,671.64 / $3,177.69
| Professional | | $1,426.78 | $1,671.64 | $3,177.69 |