- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,586.23 / $2,586.23 / $2,586.23
| Facility | | $2,586.23 | $2,586.23 | $2,586.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.23 / $3,142.82 / $4,488.02
| Professional | | $2,586.23 | $3,142.82 | $4,488.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,048.63 / $4,697.47 / $7,037.63
| Facility | | $4,048.63 | $4,697.47 | $7,037.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $8,418.37
| Professional | | $3,429.16 | $3,429.16 | $8,418.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,429.40 / $6,474.62 / $9,219.29
| Professional | | $6,429.40 | $6,474.62 | $9,219.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,872.69 / $7,037.63 / $7,037.63
| Professional | | $6,872.69 | $7,037.63 | $7,037.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,173.29 / $4,019.12 / $7,037.63
| Professional | | $3,173.29 | $4,019.12 | $7,037.63 |