- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,753.63 / $2,753.63 / $2,753.63
| Facility | | $2,753.63 | $2,753.63 | $2,753.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.63 / $3,135.75 / $3,135.75
| Professional | | $2,753.63 | $3,135.75 | $3,135.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,538.80 / $4,184.10 / $4,288.18
| Professional | | $3,538.80 | $4,184.10 | $4,288.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,340.25 / $4,383.64 / $5,512.12
| Professional | | $4,340.25 | $4,383.64 | $5,512.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,647.81 / $2,929.79 / $17,433.41
| Facility | | $1,647.81 | $2,929.79 | $17,433.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.82 / $2,502.71 / $3,060.87
| Professional | | $1,507.82 | $2,502.71 | $3,060.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.32 / $1,668.47 / $3,015.64
| Professional | | $1,112.32 | $1,668.47 | $3,015.64 |