- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,206.28 / $5,206.28 / $5,206.28
| Facility | | $5,206.28 | $5,206.28 | $5,206.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,234.43 / $5,439.61 / $6,505.46
| Professional | | $4,234.43 | $5,439.61 | $6,505.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,084.98 / $7,887.43 / $9,446.64
| Professional | | $7,084.98 | $7,887.43 | $9,446.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,899.36 / $5,470.13 / $5,470.13
| Facility | | $3,899.36 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,649.60 / $5,470.13 / $5,470.13
| Professional | | $4,649.60 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $7,602.76 / $7,602.76
| Facility | | $64.00 | $7,602.76 | $7,602.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.59 / $3,224.53 / $4,848.49
| Professional | | $1,842.59 | $3,224.53 | $4,848.49 |