- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,558.37 / $4,558.37 / $4,558.37
| Facility | | $4,558.37 | $4,558.37 | $4,558.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,558.37 / $4,849.53 / $4,849.53
| Professional | | $4,558.37 | $4,849.53 | $4,849.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,858.16 / $6,926.41 / $7,098.71
| Professional | | $5,858.16 | $6,926.41 | $7,098.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,712.13 / $6,779.25 / $8,524.40
| Professional | | $6,712.13 | $6,779.25 | $8,524.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,287.37 / $4,849.53 / $27,462.75
| Facility | | $2,287.37 | $4,849.53 | $27,462.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.04 / $3,902.28 / $5,066.99
| Professional | | $2,269.04 | $3,902.28 | $5,066.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.35 / $3,902.28 / $4,992.10
| Professional | | $1,734.35 | $3,902.28 | $4,992.10 |