- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,472.19 / $2,472.19 / $2,472.19
| Facility | | $2,472.19 | $2,472.19 | $2,472.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,472.19 / $3,021.27 / $3,021.27
| Professional | | $2,472.19 | $3,021.27 | $3,021.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,177.12 / $3,756.48 / $3,849.92
| Professional | | $3,177.12 | $3,756.48 | $3,849.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,181.63 / $4,223.43 / $5,310.66
| Professional | | $4,181.63 | $4,223.43 | $5,310.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.55 / $2,983.04 / $16,835.74
| Facility | | $1,526.55 | $2,983.04 | $16,835.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.72 / $2,409.26 / $3,158.80
| Professional | | $1,353.72 | $2,409.26 | $3,158.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.78 / $2,409.26 / $2,748.04
| Professional | | $1,070.78 | $2,409.26 | $2,748.04 |