- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,147.51 / $2,147.51 / $2,147.51
| Facility | | $2,147.51 | $2,147.51 | $2,147.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.32 / $2,282.56 / $3,158.50
| Professional | | $1,987.32 | $2,282.56 | $3,158.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $5,843.77
| Facility | | $2,780.72 | $2,780.72 | $5,843.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,029.93 / $5,117.01
| Professional | | $2,029.93 | $2,029.93 | $5,117.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,338.71 / $5,376.27 / $7,655.34
| Professional | | $5,338.71 | $5,376.27 | $7,655.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,706.81 / $5,843.77 / $5,843.77
| Professional | | $5,706.81 | $5,843.77 | $5,843.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.13 / $2,960.17 / $5,843.77
| Professional | | $2,220.13 | $2,960.17 | $5,843.77 |