- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,229.29 / $1,229.29 / $1,229.29
| Facility | | $1,229.29 | $1,229.29 | $1,229.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.29 / $1,493.85 / $2,174.90
| Professional | | $1,229.29 | $1,493.85 | $2,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $3,345.13
| Facility | | $2,217.07 | $2,217.07 | $3,345.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $1,618.46 / $2,929.12
| Professional | | $1,618.46 | $1,618.46 | $2,929.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,056.02 / $3,077.52 / $4,382.12
| Professional | | $3,056.02 | $3,077.52 | $4,382.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,266.73 / $3,345.13 / $3,345.13
| Professional | | $3,266.73 | $3,345.13 | $3,345.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,018.42 / $2,300.87 / $3,345.13
| Facility | | $2,018.42 | $2,300.87 | $3,345.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.33 / $1,736.07 / $3,345.13
| Professional | | $1,508.33 | $1,736.07 | $3,345.13 |