- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,184.74 / $3,184.74 / $3,184.74
| Facility | | $3,184.74 | $3,184.74 | $3,184.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.74 / $4,268.32 / $4,268.32
| Professional | | $3,184.74 | $4,268.32 | $4,268.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,092.84 / $4,839.18 / $4,959.56
| Professional | | $4,092.84 | $4,839.18 | $4,959.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,907.75 / $5,966.83 / $7,502.84
| Professional | | $5,907.75 | $5,966.83 | $7,502.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,986.64 / $3,877.02 / $21,089.02
| Facility | | $2,986.64 | $3,877.02 | $21,089.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.88 / $2,962.65 / $3,540.08
| Professional | | $1,743.88 | $2,962.65 | $3,540.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,962.65 / $3,487.76
| Professional | | $1,316.73 | $2,962.65 | $3,487.76 |