- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,232.52 / $4,232.52 / $4,232.52
| Facility | | $4,232.52 | $4,232.52 | $4,232.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,232.52 / $4,810.22 / $4,810.22
| Professional | | $4,232.52 | $4,810.22 | $4,810.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,439.38 / $6,431.27 / $6,591.25
| Professional | | $5,439.38 | $6,431.27 | $6,591.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,657.75 / $6,724.33 / $8,455.34
| Professional | | $6,657.75 | $6,724.33 | $8,455.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.73 / $4,496.17 / $26,749.15
| Facility | | $2,527.73 | $4,496.17 | $26,749.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,317.62 / $3,840.14 / $4,704.77
| Professional | | $2,317.62 | $3,840.14 | $4,704.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.73 / $2,560.09 / $4,635.24
| Professional | | $1,706.73 | $2,560.09 | $4,635.24 |