- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,631.71 / $2,631.71 / $2,631.71
| Facility | | $2,631.71 | $2,631.71 | $2,631.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,631.71 / $3,214.82 / $3,214.82
| Professional | | $2,631.71 | $3,214.82 | $3,214.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,382.13 / $3,998.87 / $4,098.35
| Professional | | $3,382.13 | $3,998.87 | $4,098.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,449.75 / $4,494.25 / $5,651.18
| Professional | | $4,449.75 | $4,494.25 | $5,651.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.71 / $3,214.82 / $17,674.86
| Facility | | $1,845.71 | $3,214.82 | $17,674.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.06 / $2,477.41 / $2,925.35
| Professional | | $1,441.06 | $2,477.41 | $2,925.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,182.50 / $2,182.50 / $2,182.50
| Facility | | $2,182.50 | $2,182.50 | $2,182.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.07 / $2,477.41 / $2,882.12
| Professional | | $1,101.07 | $2,477.41 | $2,882.12 |