- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,303.53 / $2,303.53 / $2,303.53
| Facility | | $2,303.53 | $2,303.53 | $2,303.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.30 / $2,453.03 / $3,609.85
| Professional | | $2,058.30 | $2,453.03 | $3,609.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,618.59 / $3,798.08 / $6,268.35
| Facility | | $3,618.59 | $3,798.08 | $6,268.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $2,772.60 / $5,488.78
| Professional | | $2,772.60 | $2,772.60 | $5,488.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,726.60 / $5,766.88 / $8,211.54
| Professional | | $5,726.60 | $5,766.88 | $8,211.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,121.43 / $6,268.35 / $6,268.35
| Professional | | $6,121.43 | $6,268.35 | $6,268.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.41 / $3,127.21 / $6,268.35
| Professional | | $2,345.41 | $3,127.21 | $6,268.35 |