- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,825.66 / $1,825.66 / $1,825.66
| Facility | | $1,825.66 | $1,825.66 | $1,825.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.66 / $2,034.31 / $2,667.28
| Professional | | $1,825.66 | $2,034.31 | $2,667.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $3,600.52 / $4,967.95
| Facility | | $3,600.52 | $3,600.52 | $4,967.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,060.44 / $4,350.10
| Professional | | $3,060.44 | $3,060.44 | $4,350.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,538.59 / $4,570.51 / $6,508.01
| Professional | | $4,538.59 | $4,570.51 | $6,508.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.33 / $2,298.33 / $3,304.61
| Professional | | $2,298.33 | $2,298.33 | $3,304.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.03 / $2,478.46 / $4,560.82
| Professional | | $2,054.03 | $2,478.46 | $4,560.82 |