- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $2,570.40
| Professional | | $1,659.59 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,691.53
| Professional | | $2,089.30 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,388.44
| Professional | | $2,398.83 | $2,398.83 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,495.41 / $7,585.78
| Professional | | $2,570.40 | $5,495.41 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $2,951.21
| Professional | | $1,288.25 | $1,905.46 | $2,951.21 |