- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,026.10 / $4,026.10 / $4,026.10
| Facility | | $4,026.10 | $4,026.10 | $4,026.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,026.10 / $4,226.82 / $4,601.26
| Professional | | $4,026.10 | $4,226.82 | $4,601.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $4,697.47 / $4,697.47
| Facility | | $4,697.47 | $4,697.47 | $4,697.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $8,418.37
| Professional | | $3,429.16 | $3,429.16 | $8,418.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,266.64 / $5,635.77 / $35,737.98
| Facility | | $2,266.64 | $5,635.77 | $35,737.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.66 / $4,639.58 / $9,163.58
| Professional | | $2,340.66 | $4,639.58 | $9,163.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,340.66 / $4,472.62 / $5,288.82
| Professional | | $2,340.66 | $4,472.62 | $5,288.82 |