- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,811.38 / $2,811.38 / $2,811.38
| Facility | | $2,811.38 | $2,811.38 | $2,811.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,286.59 / $2,961.32 / $3,520.57
| Professional | | $2,286.59 | $2,961.32 | $3,520.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,398.10 / $4,691.32 / $6,023.33
| Professional | | $4,398.10 | $4,691.32 | $6,023.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.44 / $2,446.40 / $3,331.31
| Professional | | $2,079.44 | $2,446.40 | $3,331.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,607.29 / $4,847.72 / $4,847.72
| Facility | | $3,607.29 | $4,847.72 | $4,847.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.25 / $1,798.88 / $3,072.00
| Professional | | $995.25 | $1,798.88 | $3,072.00 |