- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,516.07 / $3,516.07 / $3,516.07
| Facility | | $3,516.07 | $3,516.07 | $3,516.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,516.07 / $4,632.92 / $4,632.92
| Professional | | $3,516.07 | $4,632.92 | $4,632.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,518.64 / $5,342.63 / $5,475.53
| Professional | | $4,518.64 | $5,342.63 | $5,475.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,412.50 / $6,476.63 / $8,143.88
| Professional | | $6,412.50 | $6,476.63 | $8,143.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,115.87 / $4,554.54 / $25,854.57
| Facility | | $2,115.87 | $4,554.54 | $25,854.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.31 / $3,616.52 / $4,018.36
| Professional | | $1,925.31 | $3,616.52 | $4,018.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.24 / $3,823.86 / $6,858.69
| Professional | | $1,366.24 | $3,823.86 | $6,858.69 |