- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.20 / $1,191.20 / $1,191.20
| Facility | | $1,191.20 | $1,191.20 | $1,191.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.20 / $1,268.52 / $1,925.43
| Professional | | $1,191.20 | $1,268.52 | $1,925.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,749.85 / $2,125.02 / $3,241.50
| Facility | | $1,749.85 | $2,125.02 | $3,241.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.26 / $1,551.26 / $2,838.37
| Professional | | $1,551.26 | $1,551.26 | $2,838.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.35 / $2,982.18 / $4,246.37
| Professional | | $2,961.35 | $2,982.18 | $4,246.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,165.53 / $3,241.50 / $3,241.50
| Professional | | $3,165.53 | $3,241.50 | $3,241.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.44 / $1,705.20 / $2,975.86
| Professional | | $1,455.44 | $1,705.20 | $2,975.86 |