- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,168.69 / $4,466.84
| Professional | | $2,290.87 | $4,168.69 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,265.80
| Professional | | $3,981.07 | $3,981.07 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,128.61 / $6,165.95
| Professional | | $4,786.30 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,715.35 / $4,265.80
| Professional | | $3,388.44 | $3,715.35 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,168.69 / $5,370.32
| Professional | | $3,235.94 | $4,168.69 | $5,370.32 |