- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,305.29 / $2,305.29 / $2,305.29
| Facility | | $2,305.29 | $2,305.29 | $2,305.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,284.96 / $2,305.29 / $2,479.44
| Professional | | $2,284.96 | $2,305.29 | $2,479.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,055.82 / $6,458.42 / $8,462.27
| Facility | | $3,055.82 | $6,458.42 | $8,462.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,055.82 / $3,290.88 / $5,641.51
| Professional | | $3,055.82 | $3,290.88 | $5,641.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,798.08 / $3,798.08 / $6,094.62
| Facility | | $3,798.08 | $3,798.08 | $6,094.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $3,798.08 / $25,544.41
| Professional | | $2,772.60 | $3,798.08 | $25,544.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.41 / $2,827.13 / $3,679.55
| Professional | | $2,345.41 | $2,827.13 | $3,679.55 |