- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,245.80 / $2,245.80 / $2,245.80
| Facility | | $2,245.80 | $2,245.80 | $2,245.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.80 / $2,729.12 / $4,589.03
| Professional | | $2,245.80 | $2,729.12 | $4,589.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,545.25 / $4,728.96 / $6,111.24
| Facility | | $3,545.25 | $4,728.96 | $6,111.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $3,452.14 / $5,351.21
| Professional | | $3,452.14 | $3,452.14 | $5,351.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,583.07 / $5,622.34 / $8,005.72
| Professional | | $5,583.07 | $5,622.34 | $8,005.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,968.00 / $6,111.24 / $6,111.24
| Professional | | $5,968.00 | $6,111.24 | $6,111.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,926.06 / $8,148.31 / $9,777.96
| Facility | | $6,926.06 | $8,148.31 | $9,777.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,755.58 / $3,266.69 / $6,111.24
| Professional | | $2,755.58 | $3,266.69 | $6,111.24 |