- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.29 / $1,026.29 / $1,026.29
| Facility | | $1,026.29 | $1,026.29 | $1,026.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.29 / $1,210.66 / $2,036.75
| Professional | | $1,026.29 | $1,210.66 | $2,036.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,792.73
| Facility | | $2,283.76 | $2,283.76 | $2,792.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $1,667.14 / $2,445.42
| Professional | | $1,667.14 | $1,667.14 | $2,445.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,551.38 / $2,569.31 / $3,658.48
| Professional | | $2,551.38 | $2,569.31 | $3,658.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,727.28 / $2,792.73 / $2,792.73
| Professional | | $2,727.28 | $2,792.73 | $2,792.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.26 / $1,492.82 / $2,792.73
| Professional | | $1,259.26 | $1,492.82 | $2,792.73 |