- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,740.49 / $3,740.49 / $3,740.49
| Facility | | $3,740.49 | $3,740.49 | $3,740.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,740.49 / $4,752.33 / $4,752.33
| Professional | | $3,740.49 | $4,752.33 | $4,752.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,807.05 / $5,683.63 / $5,825.01
| Professional | | $4,807.05 | $5,683.63 | $5,825.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,577.50 / $6,643.28 / $8,353.43
| Professional | | $6,577.50 | $6,643.28 | $8,353.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,289.39 / $4,525.14 / $24,492.50
| Facility | | $2,289.39 | $4,525.14 | $24,492.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.19 / $3,430.68 / $4,157.85
| Professional | | $2,048.19 | $3,430.68 | $4,157.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.80 / $3,627.36 / $5,957.46
| Professional | | $1,790.80 | $3,627.36 | $5,957.46 |