- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,586.36 / $1,586.36 / $1,586.36
| Facility | | $1,586.36 | $1,586.36 | $1,586.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,586.36 / $1,927.76 / $2,806.62
| Professional | | $1,586.36 | $1,927.76 | $2,806.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.59 / $3,060.59 / $4,316.77
| Facility | | $3,060.59 | $3,060.59 | $4,316.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $5,127.38
| Professional | | $2,234.23 | $2,234.23 | $5,127.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,943.70 / $3,971.43 / $5,654.97
| Professional | | $3,943.70 | $3,971.43 | $5,654.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.07 / $1,997.07 / $2,871.46
| Professional | | $1,997.07 | $1,997.07 | $2,871.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.45 / $2,307.46 / $4,316.77
| Professional | | $1,946.45 | $2,307.46 | $4,316.77 |