- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,630.05 / $1,630.05 / $1,630.05
| Facility | | $1,630.05 | $1,630.05 | $1,630.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.05 / $1,816.33 / $2,381.48
| Professional | | $1,630.05 | $1,816.33 | $2,381.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $4,435.68
| Facility | | $3,214.74 | $3,214.74 | $4,435.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $3,884.04
| Professional | | $2,732.53 | $2,732.53 | $3,884.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,052.32 / $4,080.83 / $5,810.74
| Professional | | $4,052.32 | $4,080.83 | $5,810.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.09 / $2,052.09 / $2,950.55
| Professional | | $2,052.09 | $2,052.09 | $2,950.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,833.94 / $2,281.78 / $4,435.68
| Professional | | $1,833.94 | $2,281.78 | $4,435.68 |