- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,437.13 / $2,437.13 / $2,437.13
| Facility | | $2,437.13 | $2,437.13 | $2,437.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,415.64 / $2,437.13 / $2,621.25
| Professional | | $2,415.64 | $2,437.13 | $2,621.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,327.88 / $6,709.66 / $8,697.70
| Facility | | $3,327.88 | $6,709.66 | $8,697.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,230.58 / $3,583.87 / $6,143.77
| Professional | | $3,230.58 | $3,583.87 | $6,143.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $5,999.77
| Facility | | $3,294.10 | $3,294.10 | $5,999.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $3,294.10 / $24,422.17
| Professional | | $2,404.69 | $3,294.10 | $24,422.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,479.54 / $3,170.22 / $3,985.08
| Professional | | $2,479.54 | $3,170.22 | $3,985.08 |