- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,031.16 / $3,009.35 / $3,009.35
| Facility | | $2,031.16 | $3,009.35 | $3,009.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $3,009.35 / $3,128.53
| Professional | | $2,979.56 | $3,009.35 | $3,128.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $4,469.34
| Facility | | $2,979.56 | $2,979.56 | $4,469.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.56 / $2,979.56 / $6,908.25
| Professional | | $2,979.56 | $2,979.56 | $6,908.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,810.90 / $2,863.13 / $2,979.55
| Facility | | $2,810.90 | $2,863.13 | $2,979.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,979.55 / $2,979.55 / $2,979.55
| Professional | | $2,979.55 | $2,979.55 | $2,979.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,855.38 / $2,979.56 / $3,128.54
| Professional | | $2,855.38 | $2,979.56 | $3,128.54 |