- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,592.83 / $1,592.83 / $1,592.83
| Facility | | $1,592.83 | $1,592.83 | $1,592.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.76 / $1,661.24 / $2,605.86
| Professional | | $1,455.76 | $1,661.24 | $2,605.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $2,381.07 / $3,719.97
| Facility | | $2,381.07 | $2,381.07 | $3,719.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.18 / $1,738.18 / $3,257.33
| Professional | | $1,738.18 | $1,738.18 | $3,257.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,398.47 / $3,422.37 / $4,873.16
| Professional | | $3,398.47 | $3,422.37 | $4,873.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,540.72 / $3,719.97 / $3,719.97
| Professional | | $3,540.72 | $3,719.97 | $3,719.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.89 / $2,231.98 / $3,719.97
| Professional | | $1,715.89 | $2,231.98 | $3,719.97 |