- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.76 / $2,145.76 / $2,145.76
| Facility | | $2,145.76 | $2,145.76 | $2,145.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.84 / $2,145.76 / $2,307.87
| Professional | | $2,126.84 | $2,145.76 | $2,307.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,930.03 / $5,907.49 / $7,657.86
| Facility | | $2,930.03 | $5,907.49 | $7,657.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,844.35 / $3,155.42 / $5,409.29
| Professional | | $2,844.35 | $3,155.42 | $5,409.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,502.67 / $2,502.67 / $5,282.51
| Facility | | $2,502.67 | $2,502.67 | $5,282.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.95 / $2,502.67 / $21,538.31
| Professional | | $1,826.95 | $2,502.67 | $21,538.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.10 / $2,625.55 / $3,424.93
| Professional | | $2,183.10 | $2,625.55 | $3,424.93 |