- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,468.19 / $2,468.19 / $2,468.19
| Facility | | $2,468.19 | $2,468.19 | $2,468.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,468.19 / $3,602.89 / $3,602.89
| Professional | | $2,468.19 | $3,602.89 | $3,602.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,172.00 / $3,750.42 / $3,843.71
| Professional | | $3,172.00 | $3,750.42 | $3,843.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,986.75 / $5,036.62 / $6,333.17
| Professional | | $4,986.75 | $5,036.62 | $6,333.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.70 / $3,111.92 / $17,790.55
| Facility | | $1,584.70 | $3,111.92 | $17,790.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.53 / $2,538.71 / $2,820.80
| Professional | | $1,351.53 | $2,538.71 | $2,820.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.32 / $2,538.71 / $2,820.80
| Professional | | $1,128.32 | $2,538.71 | $2,820.80 |