- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,928.63 / $2,928.63 / $2,928.63
| Facility | | $2,928.63 | $2,928.63 | $2,928.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.78 / $2,429.78 / $2,928.63
| Professional | | $2,429.78 | $2,429.78 | $2,928.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,933.80 / $4,603.43 / $4,683.01
| Professional | | $3,933.80 | $4,603.43 | $4,683.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,993.75 / $4,033.69 / $5,072.06
| Professional | | $3,993.75 | $4,033.69 | $5,072.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.92 / $2,928.63 / $3,307.70
| Facility | | $224.92 | $2,928.63 | $3,307.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.64 / $1,963.27 / $2,701.86
| Professional | | $981.64 | $1,963.27 | $2,701.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.11 / $1,490.67 / $2,701.86
| Professional | | $427.11 | $1,490.67 | $2,701.86 |