- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,316.92 / $4,316.92 / $4,316.92
| Facility | | $4,316.92 | $4,316.92 | $4,316.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,841.11 / $3,841.11 / $4,316.92
| Professional | | $3,841.11 | $3,841.11 | $4,316.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,547.85 / $6,559.51 / $6,722.69
| Professional | | $5,547.85 | $6,559.51 | $6,722.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,316.38 / $5,369.54 / $6,751.80
| Professional | | $5,316.38 | $5,369.54 | $6,751.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,060.84 / $4,316.92 / $23,421.34
| Facility | | $2,060.84 | $4,316.92 | $23,421.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.53 / $3,330.19 / $4,727.68
| Professional | | $1,906.53 | $3,330.19 | $4,727.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.08 / $3,330.19 / $4,727.68
| Professional | | $1,480.08 | $3,330.19 | $4,727.68 |