- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.83 / $1,273.83 / $1,273.83
| Facility | | $1,273.83 | $1,273.83 | $1,273.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.83 / $1,586.72 / $2,133.41
| Professional | | $1,273.83 | $1,586.72 | $2,133.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,043.96 / $2,476.09 / $3,466.35
| Facility | | $2,043.96 | $2,476.09 | $3,466.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $1,807.55 / $3,035.26
| Professional | | $1,807.55 | $1,807.55 | $3,035.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,166.77 / $3,189.04 / $4,540.92
| Professional | | $3,166.77 | $3,189.04 | $4,540.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,385.11 / $3,466.35 / $3,466.35
| Professional | | $3,385.11 | $3,466.35 | $3,466.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,585.34 / $1,798.97 / $3,182.28
| Professional | | $1,585.34 | $1,798.97 | $3,182.28 |