- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,471.68 / $3,471.68 / $3,471.68
| Facility | | $3,471.68 | $3,471.68 | $3,471.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.63 / $3,656.83 / $4,371.41
| Professional | | $2,823.63 | $3,656.83 | $4,371.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,010.08 / $5,567.44 / $6,680.10
| Professional | | $5,010.08 | $5,567.44 | $6,680.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.05 / $2,673.00 / $4,219.47
| Professional | | $2,272.05 | $2,673.00 | $4,219.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,320.59 / $5,376.08 / $5,376.08
| Facility | | $4,320.59 | $5,376.08 | $5,376.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.77 / $2,080.44 / $3,422.54
| Professional | | $1,228.77 | $2,080.44 | $3,422.54 |