- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.38 / $2,979.38 / $2,979.38
| Facility | | $2,979.38 | $2,979.38 | $2,979.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.38 / $3,403.48 / $3,403.48
| Professional | | $2,979.38 | $3,403.48 | $3,403.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,828.93 / $4,527.14 / $4,639.76
| Professional | | $3,828.93 | $4,527.14 | $4,639.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,710.75 / $4,757.85 / $5,982.65
| Professional | | $4,710.75 | $4,757.85 | $5,982.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.48 / $3,179.94 / $19,065.24
| Facility | | $1,788.48 | $3,179.94 | $19,065.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.44 / $2,733.80 / $3,311.82
| Professional | | $1,631.44 | $2,733.80 | $3,311.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.02 / $2,733.80 / $4,571.31
| Professional | | $1,215.02 | $2,733.80 | $4,571.31 |