- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.21 / $1,548.21 / $1,548.21
| Facility | | $1,548.21 | $1,548.21 | $1,548.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.08 / $1,881.58 / $3,371.60
| Professional | | $1,247.08 | $1,881.58 | $3,371.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.98 / $2,837.98 / $5,170.31
| Professional | | $2,837.98 | $2,837.98 | $5,170.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,876.00 / $3,876.00 / $3,876.00
| Professional | | $3,876.00 | $3,876.00 | $3,876.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,708.32 / $2,708.32 / $2,708.32
| Professional | | $2,708.32 | $2,708.32 | $2,708.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.11 / $1,999.04 / $3,432.39
| Professional | | $1,434.11 | $1,999.04 | $3,432.39 |