- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,155.69 / $2,155.69 / $2,155.69
| Facility | | $2,155.69 | $2,155.69 | $2,155.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.69 / $2,155.69 / $2,318.57
| Professional | | $2,155.69 | $2,155.69 | $2,318.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,857.53 / $5,684.99 / $7,693.35
| Facility | | $2,857.53 | $5,684.99 | $7,693.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,857.53 / $3,077.34 / $5,053.32
| Professional | | $2,857.53 | $3,077.34 | $5,053.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,364.97 / $3,364.97 / $5,215.55
| Facility | | $3,364.97 | $3,364.97 | $5,215.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.42 / $3,364.97 / $21,859.95
| Professional | | $2,456.42 | $3,364.97 | $21,859.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.21 / $2,835.07 / $3,655.36
| Professional | | $2,193.21 | $2,835.07 | $3,655.36 |