- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,808.94 / $2,808.94 / $2,808.94
| Facility | | $2,808.94 | $2,808.94 | $2,808.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,808.94 / $3,192.39 / $3,192.39
| Professional | | $2,808.94 | $3,192.39 | $3,192.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,609.90 / $4,268.17 / $4,374.35
| Professional | | $3,609.90 | $4,268.17 | $4,374.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,418.63 / $4,462.81 / $5,611.65
| Professional | | $4,418.63 | $4,462.81 | $5,611.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.19 / $3,088.68 / $17,752.32
| Facility | | $2,569.19 | $3,088.68 | $17,752.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.11 / $2,548.54 / $3,122.36
| Professional | | $1,538.11 | $2,548.54 | $3,122.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.68 / $1,926.13 / $3,076.22
| Professional | | $1,132.68 | $1,926.13 | $3,076.22 |