- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.68 / $3,297.68 / $3,297.68
| Facility | | $3,297.68 | $3,297.68 | $3,297.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,297.68 / $3,755.33 / $3,755.33
| Professional | | $3,297.68 | $3,755.33 | $3,755.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,237.99 / $5,010.80 / $5,135.45
| Professional | | $4,237.99 | $5,010.80 | $5,135.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,197.50 / $5,249.48 / $6,600.83
| Professional | | $5,197.50 | $5,249.48 | $6,600.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,973.38 / $3,508.69 / $20,912.72
| Facility | | $1,973.38 | $3,508.69 | $20,912.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.73 / $2,997.20 / $3,665.62
| Professional | | $1,805.73 | $2,997.20 | $3,665.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.09 / $2,997.20 / $4,753.55
| Professional | | $1,332.09 | $2,997.20 | $4,753.55 |