- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.44 / $3,745.44 / $3,745.44
| Facility | | $3,745.44 | $3,745.44 | $3,745.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,745.44 / $4,265.22 / $4,265.22
| Professional | | $3,745.44 | $4,265.22 | $4,265.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,813.41 / $5,691.15 / $5,832.73
| Professional | | $4,813.41 | $5,691.15 | $5,832.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,903.25 / $5,962.28 / $7,497.13
| Professional | | $5,903.25 | $5,962.28 | $7,497.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,241.32 / $3,985.08 / $23,712.81
| Facility | | $2,241.32 | $3,985.08 | $23,712.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,050.91 / $3,404.17 / $4,163.35
| Professional | | $2,050.91 | $3,404.17 | $4,163.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.96 / $3,404.17 / $4,101.82
| Professional | | $1,512.96 | $3,404.17 | $4,101.82 |