- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.92 / $2,238.92 / $2,238.92
| Facility | | $2,238.92 | $2,238.92 | $2,238.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.92 / $2,238.92 / $2,408.08
| Professional | | $2,238.92 | $2,238.92 | $2,408.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,967.85 / $6,332.29 / $8,218.66
| Facility | | $2,967.85 | $6,332.29 | $8,218.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,967.85 / $3,196.14 / $5,479.10
| Professional | | $2,967.85 | $3,196.14 | $5,479.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $5,988.79
| Facility | | $2,853.06 | $2,853.06 | $5,988.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $25,100.82
| Professional | | $2,082.73 | $2,853.06 | $25,100.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,277.89 / $3,010.10 / $3,796.48
| Professional | | $2,277.89 | $3,010.10 | $3,796.48 |