- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,597.24 / $3,597.24 / $3,597.24
| Facility | | $3,597.24 | $3,597.24 | $3,597.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.15 / $3,586.08 / $3,597.24
| Professional | | $2,546.15 | $3,586.08 | $3,597.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.44 / $5,773.12 / $6,832.10
| Facility | | $840.44 | $5,773.12 | $6,832.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,176.20 / $5,189.02 / $11,176.34
| Professional | | $4,176.20 | $5,189.02 | $11,176.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,653.47 / $16,673.84 / $22,641.37
| Facility | | $13,653.47 | $16,673.84 | $22,641.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,176.20 / $5,115.47 / $6,960.34
| Professional | | $4,176.20 | $5,115.47 | $6,960.34 |