- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,701.66 / $2,701.66 / $2,701.66
| Facility | | $2,701.66 | $2,701.66 | $2,701.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,452.51 / $2,751.49 / $2,751.49
| Professional | | $2,452.51 | $2,751.49 | $2,751.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,472.01 / $4,105.14 / $4,207.26
| Professional | | $3,472.01 | $4,105.14 | $4,207.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,808.13 / $3,846.21 / $4,836.32
| Professional | | $3,808.13 | $3,846.21 | $4,836.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.04 / $2,701.66 / $14,520.96
| Facility | | $1,318.04 | $2,701.66 | $14,520.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.48 / $2,084.14 / $2,958.72
| Professional | | $1,307.48 | $2,084.14 | $2,958.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.28 / $1,852.57 / $2,958.72
| Professional | | $926.28 | $1,852.57 | $2,958.72 |