- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.33 / $1,185.33 / $1,185.33
| Facility | | $1,185.33 | $1,185.33 | $1,185.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.33 / $1,554.15 / $2,054.83
| Professional | | $1,185.33 | $1,554.15 | $2,054.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,974.31 / $2,425.11 / $3,225.50
| Facility | | $1,974.31 | $2,425.11 | $3,225.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $1,770.33 / $2,824.36
| Professional | | $1,770.33 | $1,770.33 | $2,824.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,946.75 / $2,967.46 / $4,225.41
| Professional | | $2,946.75 | $2,967.46 | $4,225.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,070.08 / $3,225.50 / $3,225.50
| Professional | | $3,070.08 | $3,225.50 | $3,225.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.81 / $1,609.17 / $2,961.18
| Professional | | $1,487.81 | $1,609.17 | $2,961.18 |