- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,344.07 / $3,344.07 / $3,344.07
| Facility | | $3,344.07 | $3,344.07 | $3,344.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,344.07 / $3,808.10 / $3,808.10
| Professional | | $3,344.07 | $3,808.10 | $3,808.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,297.60 / $5,081.28 / $5,207.68
| Professional | | $4,297.60 | $5,081.28 | $5,207.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,270.63 / $5,323.33 / $6,693.69
| Professional | | $5,270.63 | $5,323.33 | $6,693.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,001.13 / $3,677.09 / $21,171.57
| Facility | | $2,001.13 | $3,677.09 | $21,171.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.13 / $3,039.35 / $3,717.19
| Professional | | $1,831.13 | $3,039.35 | $3,717.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.20 / $2,026.24 / $3,717.19
| Professional | | $1,148.20 | $2,026.24 | $3,717.19 |