- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,994.22 / $3,994.22 / $3,994.22
| Facility | | $3,994.22 | $3,994.22 | $3,994.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,994.22 / $4,917.77 / $4,917.77
| Professional | | $3,994.22 | $4,917.77 | $4,917.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,133.13 / $6,069.17 / $6,220.15
| Professional | | $5,133.13 | $6,069.17 | $6,220.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,806.63 / $6,874.69 / $8,644.41
| Professional | | $6,806.63 | $6,874.69 | $8,644.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,058.30 / $4,640.79 / $24,802.46
| Facility | | $2,058.30 | $4,640.79 | $24,802.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.81 / $3,518.11 / $4,439.88
| Professional | | $2,041.81 | $3,518.11 | $4,439.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.60 / $2,440.94 / $4,374.27
| Professional | | $1,563.60 | $2,440.94 | $4,374.27 |