- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,134.67 / $2,134.67 / $2,134.67
| Facility | | $2,134.67 | $2,134.67 | $2,134.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,114.87 / $2,134.67 / $2,295.94
| Professional | | $2,114.87 | $2,134.67 | $2,295.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,829.65 / $5,575.65 / $7,618.29
| Facility | | $2,829.65 | $5,575.65 | $7,618.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,829.65 / $3,047.32 / $4,956.13
| Professional | | $2,829.65 | $3,047.32 | $4,956.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $5,049.42
| Facility | | $3,148.57 | $3,148.57 | $5,049.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $3,148.57 / $21,163.66
| Professional | | $2,298.46 | $3,148.57 | $21,163.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.82 / $2,878.29 / $3,619.70
| Professional | | $2,171.82 | $2,878.29 | $3,619.70 |