- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,021.26 / $2,021.26 / $2,021.26
| Facility | | $2,021.26 | $2,021.26 | $2,021.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,021.26 / $2,252.23 / $2,953.03
| Professional | | $2,021.26 | $2,252.23 | $2,953.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $5,500.23
| Facility | | $2,802.84 | $2,802.84 | $5,500.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,382.41 / $4,816.18
| Professional | | $2,382.41 | $2,382.41 | $4,816.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,024.87 / $5,060.21 / $7,205.30
| Professional | | $5,024.87 | $5,060.21 | $7,205.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,544.58 / $2,544.58 / $3,658.66
| Professional | | $2,544.58 | $2,544.58 | $3,658.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,469.60 / $2,940.09 / $5,500.23
| Professional | | $2,469.60 | $2,940.09 | $5,500.23 |