- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,025.46 / $3,025.46 / $3,025.46
| Facility | | $3,025.46 | $3,025.46 | $3,025.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,634.24 / $3,260.20
| Professional | | $2,608.16 | $2,634.24 | $3,260.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,196.55 / $3,609.00 / $4,150.35
| Facility | | $3,196.55 | $3,609.00 | $4,150.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.71 / $2,673.43 / $3,434.25
| Professional | | $1,825.71 | $2,673.43 | $3,434.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.12 / $5,124.88 / $7,357.50
| Facility | | $3,704.12 | $5,124.88 | $7,357.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,868.98 / $3,535.15 / $3,721.06
| Professional | | $2,868.98 | $3,535.15 | $3,721.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |