- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,261.45 / $3,261.45 / $3,261.45
| Facility | | $3,261.45 | $3,261.45 | $3,261.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,652.65 / $3,304.94 / $4,076.38
| Professional | | $2,652.65 | $3,304.94 | $4,076.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,308.37 / $4,411.16 / $4,994.33
| Professional | | $3,308.37 | $4,411.16 | $4,994.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.12 / $3,248.38 / $3,248.38
| Professional | | $2,761.12 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,065.79 / $27,719.97 / $28,730.61
| Facility | | $5,065.79 | $27,719.97 | $28,730.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.84 / $2,812.62 / $4,081.90
| Professional | | $1,730.84 | $2,812.62 | $4,081.90 |