- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,112.53 / $5,112.53 / $5,112.53
| Facility | | $5,112.53 | $5,112.53 | $5,112.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,158.18 / $5,180.68 / $6,144.92
| Professional | | $4,158.18 | $5,180.68 | $6,144.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,024.22 / $7,229.06 / $8,508.78
| Professional | | $6,024.22 | $7,229.06 | $8,508.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,170.18 / $5,587.01 / $5,587.01
| Facility | | $4,170.18 | $5,587.01 | $5,587.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,748.96 / $5,587.01 / $6,653.09
| Professional | | $4,748.96 | $5,587.01 | $6,653.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $6,464.83 / $6,464.83
| Facility | | $64.00 | $6,464.83 | $6,464.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,809.09 / $2,902.53 / $4,282.32
| Professional | | $1,809.09 | $2,902.53 | $4,282.32 |