- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,987.71 / $3,109.05 / $6,961.36
| Facility | | $2,987.71 | $3,109.05 | $6,961.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,987.71 / $2,987.71 / $2,987.71
| Professional | | $2,987.71 | $2,987.71 | $2,987.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,373.33 / $3,373.33 / $3,831.73
| Professional | | $3,373.33 | $3,373.33 | $3,831.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $3,855.99 / $3,855.99
| Professional | | $3,855.99 | $3,855.99 | $3,855.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,643.43 / $3,643.43 / $11,126.80
| Professional | | $3,643.43 | $3,643.43 | $11,126.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,864.28 / $2,796.41 / $3,961.59
| Professional | | $1,864.28 | $2,796.41 | $3,961.59 |