- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $4,786.30
| Professional | | $2,041.74 | $2,818.38 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $5,248.07
| Facility | | $3,715.35 | $3,715.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,715.35
| Professional | | $2,691.53 | $2,691.53 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,623.41 / $7,762.47
| Professional | | $3,467.37 | $5,623.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Professional | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,248.07 / $6,918.31
| Facility | | $3,388.44 | $5,248.07 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,754.23 / $4,265.80
| Professional | | $2,344.23 | $2,754.23 | $4,265.80 |