- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,520.85 / $2,520.85 / $2,520.85
| Facility | | $2,520.85 | $2,520.85 | $2,520.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,520.85 / $2,870.69 / $2,870.69
| Professional | | $2,520.85 | $2,870.69 | $2,870.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,239.65 / $3,830.41 / $3,925.69
| Professional | | $3,239.65 | $3,830.41 | $3,925.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,973.13 / $4,012.86 / $5,045.87
| Professional | | $3,973.13 | $4,012.86 | $5,045.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,508.50 / $2,682.16 / $16,018.84
| Facility | | $1,508.50 | $2,682.16 | $16,018.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.36 / $2,291.16 / $2,802.12
| Professional | | $1,380.36 | $2,291.16 | $2,802.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,018.42 / $2,018.42 / $2,018.42
| Facility | | $2,018.42 | $2,018.42 | $2,018.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.29 / $2,291.16 / $3,427.30
| Professional | | $1,018.29 | $2,291.16 | $3,427.30 |