- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,630.72 / $1,630.72 / $1,630.72
| Facility | | $1,630.72 | $1,630.72 | $1,630.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.72 / $1,981.68 / $2,885.12
| Professional | | $1,630.72 | $1,981.68 | $2,885.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $4,437.52
| Facility | | $2,941.06 | $2,941.06 | $4,437.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $5,270.63
| Professional | | $2,146.96 | $2,146.96 | $5,270.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,054.00 / $4,082.52 / $5,813.15
| Professional | | $4,054.00 | $4,082.52 | $5,813.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,885.65 / $4,333.52 / $4,437.52
| Professional | | $3,885.65 | $4,333.52 | $4,437.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.89 / $2,395.69 / $4,437.52
| Professional | | $2,000.89 | $2,395.69 | $4,437.52 |