- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,680.93 / $2,680.93 / $2,680.93
| Facility | | $2,680.93 | $2,680.93 | $2,680.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.82 / $2,964.61 / $2,964.61
| Professional | | $2,540.82 | $2,964.61 | $2,964.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,445.37 / $4,073.65 / $4,174.97
| Professional | | $3,445.37 | $4,073.65 | $4,174.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,103.25 / $4,144.28 / $5,211.13
| Professional | | $4,103.25 | $4,144.28 | $5,211.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,455.91 / $2,680.93 / $15,617.77
| Facility | | $1,455.91 | $2,680.93 | $15,617.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,439.45 / $2,159.17 / $2,936.02
| Professional | | $1,439.45 | $2,159.17 | $2,936.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.07 / $2,282.94 / $3,716.39
| Professional | | $1,127.07 | $2,282.94 | $3,716.39 |