- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.53 / $1,640.53 / $1,640.53
| Facility | | $1,640.53 | $1,640.53 | $1,640.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.53 / $1,988.05 / $2,687.35
| Professional | | $1,640.53 | $1,988.05 | $2,687.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $4,464.20
| Facility | | $2,741.63 | $2,741.63 | $4,464.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $3,909.01
| Professional | | $2,001.39 | $2,001.39 | $3,909.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,078.37 / $4,107.06 / $5,848.10
| Professional | | $4,078.37 | $4,107.06 | $5,848.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,359.57 / $4,464.20 / $4,464.20
| Professional | | $4,359.57 | $4,464.20 | $4,464.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.92 / $2,549.44 / $4,464.20
| Professional | | $2,012.92 | $2,549.44 | $4,464.20 |