- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.36 / $2,326.37 / $2,861.44
| Facility | | $2,326.36 | $2,326.37 | $2,861.44 |
- 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
- $2,226.21 / $2,554.44 / $2,880.99
| Facility | | $2,226.21 | $2,554.44 | $2,880.99 |
- 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
- $4,478.01 / $5,113.89 / $10,573.16
| Facility | | $4,478.01 | $5,113.89 | $10,573.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.00 / $113.00 / $113.00
| Professional | | $113.00 | $113.00 | $113.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,349.17 / $2,584.10 / $2,772.03
| Professional | | $2,349.17 | $2,584.10 | $2,772.03 |