- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,268.48 / $2,268.48 / $2,268.48
| Facility | | $2,268.48 | $2,268.48 | $2,268.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.48 / $2,756.68 / $4,675.47
| Professional | | $2,268.48 | $2,756.68 | $4,675.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,613.49 / $4,865.01 / $6,172.96
| Facility | | $3,613.49 | $4,865.01 | $6,172.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,551.46 / $3,551.46 / $5,405.26
| Professional | | $3,551.46 | $3,551.46 | $5,405.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,639.45 / $5,679.12 / $8,086.58
| Professional | | $5,639.45 | $5,679.12 | $8,086.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,028.28 / $6,172.96 / $6,172.96
| Professional | | $6,028.28 | $6,172.96 | $6,172.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,320.94 / $5,320.94 / $5,320.94
| Facility | | $5,320.94 | $5,320.94 | $5,320.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.41 / $3,247.31 / $6,172.96
| Professional | | $2,783.41 | $3,247.31 | $6,172.96 |