- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,209.08 / $4,209.08 / $4,209.08
| Facility | | $4,209.08 | $4,209.08 | $4,209.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,086.32 / $4,209.08 / $4,527.08
| Professional | | $4,086.32 | $4,209.08 | $4,527.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,579.42 / $11,279.68 / $15,021.53
| Facility | | $5,579.42 | $11,279.68 | $15,021.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,579.42 / $6,008.61 / $10,026.37
| Professional | | $5,579.42 | $6,008.61 | $10,026.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,751.45 / $4,751.45 / $9,791.39
| Facility | | $4,751.45 | $4,751.45 | $9,791.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,038.73 / $4,751.45 / $40,627.25
| Professional | | $4,038.73 | $4,751.45 | $40,627.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,282.33 / $5,714.49 / $8,385.98
| Professional | | $4,282.33 | $5,714.49 | $8,385.98 |