- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,851.89 / $2,851.89 / $2,851.89
| Facility | | $2,851.89 | $2,851.89 | $2,851.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,366.46 / $2,366.46 / $2,851.89
| Professional | | $2,366.46 | $2,366.46 | $2,851.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,924.09 / $4,592.08 / $4,671.45
| Professional | | $3,924.09 | $4,592.08 | $4,671.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,982.50 / $4,022.33 / $5,057.78
| Professional | | $3,982.50 | $4,022.33 | $5,057.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.97 / $2,851.89 / $3,744.63
| Facility | | $209.97 | $2,851.89 | $3,744.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.70 / $1,824.94 / $2,564.38
| Professional | | $957.70 | $1,824.94 | $2,564.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.54 / $1,709.59 / $2,442.27
| Professional | | $386.54 | $1,709.59 | $2,442.27 |