- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,594.10 / $4,594.10 / $4,594.10
| Facility | | $4,594.10 | $4,594.10 | $4,594.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,594.10 / $5,105.93 / $5,105.93
| Professional | | $4,594.10 | $5,105.93 | $5,105.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,904.07 / $6,980.70 / $7,154.35
| Professional | | $5,904.07 | $6,980.70 | $7,154.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,066.88 / $7,137.54 / $8,974.93
| Professional | | $7,066.88 | $7,137.54 | $8,974.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,299.98 / $5,105.93 / $27,719.31
| Facility | | $2,299.98 | $5,105.93 | $27,719.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,281.57 / $3,931.23 / $5,106.71
| Professional | | $2,281.57 | $3,931.23 | $5,106.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.21 / $3,150.24 / $5,031.24
| Professional | | $1,747.21 | $3,150.24 | $5,031.24 |