- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $2,951.21
| Professional | | $2,398.83 | $2,691.53 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,801.89
| Professional | | $2,951.21 | $2,951.21 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,801.89
| Professional | | $2,691.53 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,943.28 / $10,964.78
| Professional | | $3,630.78 | $7,943.28 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $8,317.64 / $8,317.64
| Facility | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $4,168.69
| Professional | | $1,819.70 | $2,754.23 | $4,168.69 |