- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.67 / $2,818.67 / $2,818.67
| Facility | | $2,818.67 | $2,818.67 | $2,818.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,454.19 / $3,037.36
| Professional | | $2,429.89 | $2,454.19 | $3,037.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,823.17 / $3,187.45 / $3,665.57
| Facility | | $2,823.17 | $3,187.45 | $3,665.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,429.89
| Professional | | $2,429.89 | $2,429.89 | $2,429.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.49 / $2,441.48 / $3,173.93
| Professional | | $1,708.49 | $2,441.48 | $3,173.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,805.12 / $4,885.59 / $6,811.64
| Facility | | $3,805.12 | $4,885.59 | $6,811.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.88 / $3,293.52 / $3,466.73
| Professional | | $2,672.88 | $3,293.52 | $3,466.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.89 / $2,429.89 / $2,429.89
| Professional | | $2,429.89 | $2,429.89 | $2,429.89 |