- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,175.96 / $2,175.96 / $2,175.96
| Facility | | $2,175.96 | $2,175.96 | $2,175.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,156.78 / $2,175.96 / $2,340.36
| Professional | | $2,156.78 | $2,175.96 | $2,340.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,971.20 / $5,990.65 / $7,765.66
| Facility | | $2,971.20 | $5,990.65 | $7,765.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.39 / $3,199.75 / $5,485.28
| Professional | | $2,884.39 | $3,199.75 | $5,485.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $5,356.73
| Facility | | $2,941.06 | $2,941.06 | $5,356.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $21,804.91
| Professional | | $2,146.96 | $2,146.96 | $21,804.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,213.83 / $2,677.55 / $3,473.12
| Professional | | $2,213.83 | $2,677.55 | $3,473.12 |