- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Facility | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.36 / $2,326.37 / $2,326.37
| Professional | | $2,326.36 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,394.80 / $2,406.77 / $2,437.67
| Facility | | $2,394.80 | $2,406.77 | $2,437.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.58 / $2,403.17 / $2,437.67
| Professional | | $2,035.58 | $2,403.17 | $2,437.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,182.50 / $2,204.33 / $2,728.13
| Professional | | $2,182.50 | $2,204.33 | $2,728.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.44 / $2,326.37 / $6,979.11
| Facility | | $149.44 | $2,326.37 | $6,979.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,551.33 / $2,584.10 / $2,736.91
| Professional | | $2,551.33 | $2,584.10 | $2,736.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.05 / $2,584.10 / $2,654.57
| Professional | | $2,248.05 | $2,584.10 | $2,654.57 |