- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,245.87 / $2,245.87 / $2,245.87
| Facility | | $2,245.87 | $2,245.87 | $2,245.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.87 / $2,708.91 / $4,346.72
| Professional | | $2,245.87 | $2,708.91 | $4,346.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $6,111.45
| Facility | | $3,790.37 | $3,790.37 | $6,111.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $2,766.97 / $5,351.40
| Professional | | $2,766.97 | $2,766.97 | $5,351.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,583.26 / $5,622.53 / $8,006.00
| Professional | | $5,583.26 | $5,622.53 | $8,006.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,968.21 / $6,111.45 / $6,111.45
| Professional | | $5,968.21 | $6,111.45 | $6,111.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,755.67 / $3,214.95 / $6,111.45
| Professional | | $2,755.67 | $3,214.95 | $6,111.45 |