- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $3,715.35
| Professional | | $2,137.96 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,677.35 / $5,888.44
| Facility | | $2,691.53 | $4,677.35 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $4,677.35
| Professional | | $2,691.53 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,623.41 / $6,606.93
| Facility | | $4,466.84 | $5,623.41 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $4,677.35
| Facility | | $2,041.74 | $2,754.23 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,073.80
| Professional | | $2,041.74 | $2,041.74 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,388.44 / $3,630.78
| Facility | | $2,951.21 | $3,388.44 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,290.87 / $3,311.31
| Professional | | $1,479.11 | $2,290.87 | $3,311.31 |