- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.73 / $2,073.73 / $2,073.73
| Facility | | $2,073.73 | $2,073.73 | $2,073.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,054.25 / $2,360.56 / $2,360.56
| Professional | | $2,054.25 | $2,360.56 | $2,360.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,665.05 / $3,151.03 / $3,229.41
| Professional | | $2,665.05 | $3,151.03 | $3,229.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,267.38 / $3,300.05 / $4,149.57
| Professional | | $3,267.38 | $3,300.05 | $4,149.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.58 / $2,180.87 / $12,483.67
| Facility | | $1,300.58 | $2,180.87 | $12,483.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.53 / $1,745.69 / $2,288.79
| Professional | | $1,135.53 | $1,745.69 | $2,288.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.86 / $1,745.69 / $2,271.06
| Professional | | $775.86 | $1,745.69 | $2,271.06 |