- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,826.45 / $1,826.45 / $1,826.45
| Facility | | $1,826.45 | $1,826.45 | $1,826.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.45 / $2,219.53 / $3,231.45
| Professional | | $1,826.45 | $2,219.53 | $3,231.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $4,970.12
| Facility | | $3,294.10 | $3,294.10 | $4,970.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $2,404.69 / $4,352.01
| Professional | | $2,404.69 | $2,404.69 | $4,352.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,540.57 / $4,572.51 / $6,510.86
| Professional | | $4,540.57 | $4,572.51 | $6,510.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,730.63 / $4,970.12 / $4,970.12
| Professional | | $4,730.63 | $4,970.12 | $4,970.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,241.05 / $2,479.54 / $4,562.81
| Professional | | $2,241.05 | $2,479.54 | $4,562.81 |