- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,961.85 / $2,961.85 / $2,961.85
| Facility | | $2,961.85 | $2,961.85 | $2,961.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.85 / $3,908.58 / $5,701.34
| Professional | | $2,961.85 | $3,908.58 | $5,701.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,759.38 / $6,300.68 / $8,059.76
| Facility | | $4,759.38 | $6,300.68 | $8,059.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,599.50 / $4,599.50 / $7,057.41
| Professional | | $4,599.50 | $4,599.50 | $7,057.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,363.19 / $7,414.98 / $10,558.29
| Professional | | $7,363.19 | $7,414.98 | $10,558.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,057.41 / $7,870.86 / $8,059.76
| Professional | | $7,057.41 | $7,870.86 | $8,059.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,634.18 / $4,308.25 / $7,399.25
| Professional | | $3,634.18 | $4,308.25 | $7,399.25 |