- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.60 / $1,272.60 / $1,272.60
| Facility | | $1,272.60 | $1,272.60 | $1,272.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.60 / $1,691.76 / $2,328.65
| Professional | | $1,272.60 | $1,691.76 | $2,328.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,139.13 / $2,782.58 / $3,463.02
| Facility | | $2,139.13 | $2,782.58 | $3,463.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.28 / $2,031.28 / $4,986.75
| Professional | | $2,031.28 | $2,031.28 | $4,986.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,163.73 / $3,185.98 / $4,536.56
| Professional | | $3,163.73 | $3,185.98 | $4,536.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,296.16 / $3,463.02 / $3,463.02
| Professional | | $3,296.16 | $3,463.02 | $3,463.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.36 / $1,869.59 / $3,463.02
| Professional | | $1,597.36 | $1,869.59 | $3,463.02 |