- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.22 / $1,375.22 / $1,375.22
| Facility | | $1,375.22 | $1,375.22 | $1,375.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.22 / $1,659.36 / $2,392.40
| Professional | | $1,375.22 | $1,659.36 | $2,392.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $3,742.23
| Facility | | $2,677.88 | $2,677.88 | $3,742.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $1,954.85 / $3,276.83
| Professional | | $1,954.85 | $1,954.85 | $3,276.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,418.81 / $3,442.85 / $4,902.32
| Professional | | $3,418.81 | $3,442.85 | $4,902.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,561.91 / $3,742.23 / $3,742.23
| Professional | | $3,561.91 | $3,742.23 | $3,742.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.39 / $2,137.15 / $3,435.56
| Professional | | $1,687.39 | $2,137.15 | $3,435.56 |