- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,292.80 / $2,339.05 / $2,339.05
| Facility | | $2,292.80 | $2,339.05 | $2,339.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,339.05 / $2,339.05 / $2,339.05
| Professional | | $2,339.05 | $2,339.05 | $2,339.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,259.85 / $2,748.00 / $2,934.16
| Facility | | $2,259.85 | $2,748.00 | $2,934.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,010.58 / $3,962.35 / $5,688.52
| Facility | | $3,010.58 | $3,962.35 | $5,688.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Professional | | $2,016.42 | $2,016.42 | $2,016.42 |