- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,191.41 / $5,191.41 / $5,191.41
| Facility | | $5,191.41 | $5,191.41 | $5,191.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,191.41 / $6,299.24 / $6,299.24
| Professional | | $5,191.41 | $6,299.24 | $6,299.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,671.69 / $7,888.30 / $8,084.52
| Professional | | $6,671.69 | $7,888.30 | $8,084.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,718.75 / $8,805.94 / $11,072.81
| Professional | | $8,718.75 | $8,805.94 | $11,072.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,817.11 / $6,093.46 / $33,007.53
| Facility | | $2,817.11 | $6,093.46 | $33,007.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,794.57 / $4,619.43 / $5,770.66
| Professional | | $2,794.57 | $4,619.43 | $5,770.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.08 / $4,619.43 / $5,685.38
| Professional | | $2,053.08 | $4,619.43 | $5,685.38 |