- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,146.40 / $3,146.40 / $3,146.40
| Facility | | $3,146.40 | $3,146.40 | $3,146.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,146.40 / $3,778.66 / $3,778.66
| Professional | | $3,146.40 | $3,778.66 | $3,778.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,043.56 / $4,780.92 / $4,899.84
| Professional | | $4,043.56 | $4,780.92 | $4,899.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,230.13 / $5,282.43 / $6,642.26
| Professional | | $5,230.13 | $5,282.43 | $6,642.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,397.95 / $3,146.40 / $21,030.00
| Facility | | $1,397.95 | $3,146.40 | $21,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.90 / $3,153.49 / $3,503.88
| Professional | | $1,722.90 | $3,153.49 | $3,503.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.55 / $3,153.49 / $4,511.30
| Professional | | $1,401.55 | $3,153.49 | $4,511.30 |