- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,471.44 / $2,471.44 / $2,471.44
| Facility | | $2,471.44 | $2,471.44 | $2,471.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,471.44 / $3,206.09 / $3,206.09
| Professional | | $2,471.44 | $3,206.09 | $3,206.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,176.17 / $3,755.35 / $3,848.77
| Professional | | $3,176.17 | $3,755.35 | $3,848.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,437.38 / $4,481.75 / $5,635.47
| Professional | | $4,437.38 | $4,481.75 | $5,635.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.67 / $3,116.08 / $16,803.40
| Facility | | $1,491.67 | $3,116.08 | $16,803.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.31 / $2,378.01 / $2,747.21
| Professional | | $1,353.31 | $2,378.01 | $2,747.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.89 / $2,378.01 / $3,771.51
| Professional | | $1,056.89 | $2,378.01 | $3,771.51 |