- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,248.12 / $2,248.12 / $2,697.74
| Facility | | $2,248.12 | $2,248.12 | $2,697.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.12 / $2,336.35 / $3,147.79
| Professional | | $2,248.12 | $2,336.35 | $3,147.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,019.14 / $4,019.14 / $5,100.00
| Professional | | $4,019.14 | $4,019.14 | $5,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $389.53
| Professional | | $248.35 | $248.35 | $389.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.85 / $266.77 / $426.05
| Professional | | $177.85 | $266.77 | $426.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,570.37 / $3,955.90 / $5,034.78
| Professional | | $3,570.37 | $3,955.90 | $5,034.78 |