- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,922.45 / $2,922.45 / $2,922.45
| Facility | | $2,922.45 | $2,922.45 | $2,922.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.26 / $2,742.35 / $3,736.03
| Professional | | $2,033.26 | $2,742.35 | $3,736.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,728.42 / $3,728.42 / $5,195.68
| Facility | | $3,728.42 | $3,728.42 | $5,195.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,721.75 / $2,721.75 / $4,549.53
| Professional | | $2,721.75 | $2,721.75 | $4,549.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,746.64 / $4,780.03 / $6,806.35
| Professional | | $4,746.64 | $4,780.03 | $6,806.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,073.92 / $5,195.68 / $5,195.68
| Professional | | $5,073.92 | $5,195.68 | $5,195.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.59 / $2,951.92 / $5,195.68
| Professional | | $2,396.59 | $2,951.92 | $5,195.68 |