- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,387.01 / $3,387.01 / $3,482.19
| Facility | | $3,387.01 | $3,387.01 | $3,482.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.85 / $3,284.81 / $4,363.39
| Professional | | $2,632.85 | $3,284.81 | $4,363.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,927.09 / $4,948.63 / $4,948.63
| Facility | | $2,927.09 | $4,948.63 | $4,948.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,950.27 / $3,325.33 / $3,982.62
| Professional | | $2,950.27 | $3,325.33 | $3,982.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Facility | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.27 / $3,626.76 / $3,780.00
| Professional | | $432.27 | $3,626.76 | $3,780.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.95 / $2,048.17 / $3,521.43
| Professional | | $1,494.95 | $2,048.17 | $3,521.43 |