- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,168.94 / $2,168.94 / $2,168.94
| Facility | | $2,168.94 | $2,168.94 | $2,168.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.94 / $2,470.31 / $3,434.80
| Professional | | $2,168.94 | $2,470.31 | $3,434.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,145.51 / $4,072.36 / $5,902.08
| Facility | | $3,145.51 | $4,072.36 | $5,902.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $2,972.82 / $5,168.07
| Professional | | $2,972.82 | $2,972.82 | $5,168.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,391.99 / $5,429.91 / $7,731.72
| Professional | | $5,391.99 | $5,429.91 | $7,731.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,617.69 / $5,902.08 / $5,902.08
| Professional | | $5,617.69 | $5,902.08 | $5,902.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,661.28 / $3,154.89 / $5,902.08
| Professional | | $2,661.28 | $3,154.89 | $5,902.08 |