- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,728.87 / $1,728.87 / $1,728.87
| Facility | | $1,728.87 | $1,728.87 | $1,728.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.87 / $1,944.07 / $2,633.84
| Professional | | $1,728.87 | $1,944.07 | $2,633.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $4,704.55
| Facility | | $3,148.57 | $3,148.57 | $4,704.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $2,298.46 / $4,119.47
| Professional | | $2,298.46 | $2,298.46 | $4,119.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,297.97 / $4,328.18 / $6,162.96
| Professional | | $4,297.97 | $4,328.18 | $6,162.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,477.87 / $4,704.55 / $4,704.55
| Professional | | $4,477.87 | $4,704.55 | $4,704.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.46 / $2,561.27 / $4,704.55
| Professional | | $2,060.46 | $2,561.27 | $4,704.55 |