- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,492.08 / $3,492.08 / $3,492.08
| Facility | | $3,492.08 | $3,492.08 | $3,492.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,840.22 / $3,678.32 / $4,363.39
| Professional | | $2,840.22 | $3,678.32 | $4,363.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,880.45 / $5,347.36 / $6,507.27
| Professional | | $4,880.45 | $5,347.36 | $6,507.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,644.69 / $3,626.76 / $3,626.76
| Facility | | $2,644.69 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,082.75 / $3,626.76 / $3,626.76
| Professional | | $3,082.75 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $5,237.12 / $5,237.12
| Facility | | $64.00 | $5,237.12 | $5,237.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.95 / $2,048.17 / $3,322.10
| Professional | | $1,235.95 | $2,048.17 | $3,322.10 |