- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,055.78 / $2,055.78 / $2,055.78
| Facility | | $2,055.78 | $2,055.78 | $2,055.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.78 / $2,434.46 / $3,417.58
| Professional | | $2,055.78 | $2,434.46 | $3,417.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,099.93 / $3,943.38 / $5,594.18
| Facility | | $3,099.93 | $3,943.38 | $5,594.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $2,878.67 / $4,898.46
| Professional | | $2,878.67 | $2,878.67 | $4,898.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,110.70 / $5,146.64 / $7,328.38
| Professional | | $5,110.70 | $5,146.64 | $7,328.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,463.07 / $5,594.18 / $5,594.18
| Professional | | $5,463.07 | $5,594.18 | $5,594.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,522.42 / $2,942.84 / $5,594.18
| Professional | | $2,522.42 | $2,942.84 | $5,594.18 |