- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,192.69 / $2,192.69 / $2,192.69
| Facility | | $2,192.69 | $2,192.69 | $2,192.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,192.69 / $2,192.69 / $2,896.05
| Professional | | $2,192.69 | $2,192.69 | $2,896.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.57 / $6,036.73 / $8,037.80
| Facility | | $2,906.57 | $6,036.73 | $8,037.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,906.57 / $3,130.16 / $5,365.98
| Professional | | $2,906.57 | $3,130.16 | $5,365.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $5,853.85
| Facility | | $3,813.78 | $3,813.78 | $5,853.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $3,813.78 / $24,535.25
| Professional | | $2,784.06 | $3,813.78 | $24,535.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.86 / $3,116.31 / $3,718.10
| Professional | | $2,230.86 | $3,116.31 | $3,718.10 |