- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,486.88 / $2,486.88 / $2,486.88
| Facility | | $2,486.88 | $2,486.88 | $2,486.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,486.88 / $2,486.88 / $2,884.92
| Professional | | $2,486.88 | $2,486.88 | $2,884.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,313.23 / $6,846.63 / $8,875.27
| Facility | | $3,313.23 | $6,846.63 | $8,875.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,296.53 / $3,568.10 / $6,116.74
| Professional | | $3,296.53 | $3,568.10 | $6,116.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $3,578.08 / $6,353.15
| Facility | | $3,578.08 | $3,578.08 | $6,353.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $26,627.99
| Professional | | $2,612.00 | $2,612.00 | $26,627.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,477.37 / $3,367.98 / $4,216.93
| Professional | | $2,477.37 | $3,367.98 | $4,216.93 |