- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,943.60 / $2,943.60 / $2,943.60
| Facility | | $2,943.60 | $2,943.60 | $2,943.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,943.60 / $4,026.86 / $5,746.99
| Professional | | $2,943.60 | $4,026.86 | $5,746.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,737.38 / $6,541.83 / $8,010.09
| Facility | | $4,737.38 | $6,541.83 | $8,010.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.54 / $4,775.54 / $7,013.91
| Professional | | $4,775.54 | $4,775.54 | $7,013.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,317.81 / $7,369.28 / $10,493.22
| Professional | | $7,317.81 | $7,369.28 | $10,493.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,822.35 / $8,010.09 / $8,010.09
| Professional | | $7,822.35 | $8,010.09 | $8,010.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,078.09 / $10,680.11 / $12,816.13
| Facility | | $9,078.09 | $10,680.11 | $12,816.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,694.76 / $4,574.47 / $8,010.09
| Professional | | $3,694.76 | $4,574.47 | $8,010.09 |