- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,362.09 / $2,362.09 / $2,362.09
| Facility | | $2,362.09 | $2,362.09 | $2,362.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,341.25 / $2,362.09 / $2,540.54
| Professional | | $2,341.25 | $2,362.09 | $2,540.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,225.36 / $6,503.07 / $8,429.91
| Facility | | $3,225.36 | $6,503.07 | $8,429.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,131.11 / $3,473.46 / $5,954.51
| Professional | | $3,131.11 | $3,473.46 | $5,954.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $5,814.95
| Facility | | $2,801.20 | $2,801.20 | $5,814.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $23,670.06
| Professional | | $2,044.88 | $2,044.88 | $23,670.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.19 / $3,155.55 / $4,184.25
| Professional | | $2,403.19 | $3,155.55 | $4,184.25 |