- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,477.45 / $4,477.45 / $4,477.45
| Facility | | $4,477.45 | $4,477.45 | $4,477.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,477.45 / $4,826.54 / $4,826.54
| Professional | | $4,477.45 | $4,826.54 | $4,826.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.15 / $6,803.44 / $6,972.68
| Professional | | $5,754.15 | $6,803.44 | $6,972.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,680.25 / $6,747.05 / $8,483.92
| Professional | | $6,680.25 | $6,747.05 | $8,483.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,874.88 / $4,923.34 / $26,807.65
| Facility | | $3,874.88 | $4,923.34 | $26,807.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.65 / $3,843.76 / $4,977.03
| Professional | | $2,395.65 | $3,843.76 | $4,977.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.34 / $3,070.25 / $4,903.47
| Professional | | $1,708.34 | $3,070.25 | $4,903.47 |