- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.70 / $1,486.70 / $1,486.70
| Facility | | $1,486.70 | $1,486.70 | $1,486.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.70 / $1,771.11 / $2,575.92
| Professional | | $1,486.70 | $1,771.11 | $2,575.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $2,282.71 / $4,045.58
| Facility | | $2,282.71 | $2,282.71 | $4,045.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $4,710.75
| Professional | | $1,666.39 | $1,666.39 | $4,710.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,695.94 / $3,721.93 / $5,299.71
| Professional | | $3,695.94 | $3,721.93 | $5,299.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,950.76 / $4,045.58 / $4,045.58
| Professional | | $3,950.76 | $4,045.58 | $4,045.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.54 / $2,162.51 / $4,045.58
| Professional | | $1,822.54 | $2,162.51 | $4,045.58 |