- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,559.01
| Facility | | $2,326.37 | $2,326.37 | $2,559.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Professional | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.27 / $405.20 / $3,423.26
| Facility | | $114.27 | $405.20 | $3,423.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.53 / $2,280.76 / $2,326.37
| Professional | | $2,189.53 | $2,280.76 | $2,326.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Facility | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Professional | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,964.25 / $6,103.44 / $6,402.83
| Facility | | $5,964.25 | $6,103.44 | $6,402.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.17 / $2,654.57 / $2,819.02
| Professional | | $2,349.17 | $2,654.57 | $2,819.02 |