- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,710.54 / $2,710.54 / $2,710.54
| Facility | | $2,710.54 | $2,710.54 | $2,710.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,710.54 / $3,284.26 / $4,226.84
| Professional | | $2,710.54 | $3,284.26 | $4,226.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,423.18 / $4,423.18 / $7,375.88
| Facility | | $4,423.18 | $4,423.18 | $7,375.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,228.92 / $3,228.92 / $6,458.58
| Professional | | $3,228.92 | $3,228.92 | $6,458.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,738.41 / $6,785.81 / $9,662.40
| Professional | | $6,738.41 | $6,785.81 | $9,662.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,020.48 / $7,375.88 / $7,375.88
| Professional | | $7,020.48 | $7,375.88 | $7,375.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,316.10 / $3,982.04 / $7,375.88
| Professional | | $3,316.10 | $3,982.04 | $7,375.88 |