- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,260.21 / $4,260.21 / $5,112.25
| Facility | | $4,260.21 | $4,260.21 | $5,112.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.32 / $1,794.32 / $2,149.79
| Professional | | $1,794.32 | $1,794.32 | $2,149.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,305.00 / $2,305.00 / $2,305.00
| Professional | | $2,305.00 | $2,305.00 | $2,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,273.60 / $2,535.54 / $8,230.90
| Facility | | $2,273.60 | $2,535.54 | $8,230.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,445.49 / $8,445.49 / $8,445.49
| Professional | | $8,445.49 | $8,445.49 | $8,445.49 |