- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,365.68 / $1,365.68 / $1,365.68
| Facility | | $1,365.68 | $1,365.68 | $1,365.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.68 / $1,659.59 / $2,416.17
| Professional | | $1,365.68 | $1,659.59 | $2,416.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $3,716.28
| Facility | | $2,463.07 | $2,463.07 | $3,716.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $1,798.04 / $3,254.10
| Professional | | $1,798.04 | $1,798.04 | $3,254.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,395.10 / $3,418.98 / $4,868.33
| Professional | | $3,395.10 | $3,418.98 | $4,868.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,629.18 / $3,716.28 / $3,716.28
| Professional | | $3,629.18 | $3,716.28 | $3,716.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.68 / $1,939.81 / $3,716.28
| Professional | | $1,675.68 | $1,939.81 | $3,716.28 |