- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,489.53 / $2,489.53 / $2,489.53
| Facility | | $2,489.53 | $2,489.53 | $2,489.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.75 / $2,382.62 / $2,489.53
| Professional | | $2,320.75 | $2,382.62 | $2,489.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,226.57 / $6,505.42 / $8,432.95
| Facility | | $3,226.57 | $6,505.42 | $8,432.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,132.24 / $3,474.77 / $5,956.75
| Professional | | $3,132.24 | $3,474.77 | $5,956.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $5,817.14
| Facility | | $2,756.64 | $2,756.64 | $5,817.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $23,684.18
| Professional | | $2,012.35 | $2,012.35 | $23,684.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.69 / $2,443.44 / $3,621.39
| Professional | | $1,844.69 | $2,443.44 | $3,621.39 |