- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,247.16 / $2,247.16 / $2,247.16
| Facility | | $2,247.16 | $2,247.16 | $2,247.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.69 / $2,350.00 / $5,658.33
| Professional | | $2,036.69 | $2,350.00 | $5,658.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,888.28 / $2,888.28 / $2,888.28
| Facility | | $2,888.28 | $2,888.28 | $2,888.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,415.35 / $3,091.29 / $11,892.82
| Professional | | $2,415.35 | $3,091.29 | $11,892.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.10 / $2,310.00 / $3,965.68
| Professional | | $1,847.10 | $2,310.00 | $3,965.68 |