- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,836.44 / $2,836.44 / $2,836.44
| Facility | | $2,836.44 | $2,836.44 | $2,836.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,069.05 / $2,679.48 / $2,836.44
| Professional | | $2,069.05 | $2,679.48 | $2,836.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,645.21 / $4,309.92 / $4,417.13
| Professional | | $3,645.21 | $4,309.92 | $4,417.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,470.75 / $4,515.46 / $5,677.85
| Professional | | $4,470.75 | $4,515.46 | $5,677.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,799.19 / $2,836.44 / $17,957.82
| Facility | | $1,799.19 | $2,836.44 | $17,957.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.17 / $1,908.05 / $3,106.33
| Professional | | $1,553.17 | $1,908.05 | $3,106.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.70 / $1,718.66 / $3,152.92
| Professional | | $1,345.70 | $1,718.66 | $3,152.92 |