- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,520.73 / $2,520.73 / $2,520.73
| Facility | | $2,520.73 | $2,520.73 | $2,520.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,493.27 / $2,843.48 / $2,843.48
| Professional | | $2,493.27 | $2,843.48 | $2,843.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,239.50 / $3,830.24 / $3,925.52
| Professional | | $3,239.50 | $3,830.24 | $3,925.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,935.63 / $3,974.98 / $4,998.24
| Professional | | $3,935.63 | $3,974.98 | $4,998.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,483.13 / $2,627.74 / $14,790.81
| Facility | | $1,483.13 | $2,627.74 | $14,790.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.30 / $2,118.77 / $2,777.94
| Professional | | $1,380.30 | $2,118.77 | $2,777.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.68 / $1,728.51 / $2,760.59
| Professional | | $941.68 | $1,728.51 | $2,760.59 |