- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,543.89 / $2,543.89 / $2,543.89
| Facility | | $2,543.89 | $2,543.89 | $2,543.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,868.97
| Professional | | $2,608.16 | $2,608.16 | $2,868.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,010.31 / $3,541.54 / $3,541.54
| Professional | | $3,010.31 | $3,541.54 | $3,541.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.53 / $2,460.53 / $2,460.53
| Facility | | $2,460.53 | $2,460.53 | $2,460.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $3,198.68 / $3,690.79
| Professional | | $2,608.16 | $3,198.68 | $3,690.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,346.86 / $5,346.86 / $5,881.55
| Facility | | $5,346.86 | $5,346.86 | $5,881.55 |
- 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 |