- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,485.96 / $2,485.96 / $4,922.22
| Facility | | $2,485.96 | $2,485.96 | $4,922.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,485.96 / $2,545.87
| Professional | | $2,396.11 | $2,485.96 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,745.55 / $2,995.14 / $3,294.66
| Professional | | $2,745.55 | $2,995.14 | $3,294.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Facility | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.87 / $2,545.87 / $2,545.87
| Professional | | $2,545.87 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,995.14 / $13,228.55 / $13,228.55
| Facility | | $2,995.14 | $13,228.55 | $13,228.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,381.53 / $11,381.53 / $13,478.13
| Professional | | $11,381.53 | $11,381.53 | $13,478.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.15 / $2,495.94 / $2,845.38
| Professional | | $2,371.15 | $2,495.94 | $2,845.38 |