- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,182.15 / $2,182.15 / $2,182.15
| Facility | | $2,182.15 | $2,182.15 | $2,182.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,182.15 / $2,182.15 / $2,539.08
| Professional | | $2,182.15 | $2,182.15 | $2,539.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,892.60 / $6,007.70 / $7,787.76
| Facility | | $2,892.60 | $6,007.70 | $7,787.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,892.60 / $3,115.11 / $5,340.18
| Professional | | $2,892.60 | $3,115.11 | $5,340.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $5,755.24
| Facility | | $2,780.72 | $2,780.72 | $5,755.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $24,121.98
| Professional | | $2,029.93 | $2,780.72 | $24,121.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.13 / $2,933.77 / $3,700.21
| Professional | | $2,220.13 | $2,933.77 | $3,700.21 |