- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.76 / $2,116.76 / $2,116.76
| Facility | | $2,116.76 | $2,116.76 | $2,116.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.09 / $2,116.76 / $2,276.67
| Professional | | $2,098.09 | $2,116.76 | $2,276.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,890.37 / $5,827.64 / $7,554.35
| Facility | | $2,890.37 | $5,827.64 | $7,554.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,805.90 / $3,112.71 / $5,336.08
| Professional | | $2,805.90 | $3,112.71 | $5,336.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.59 / $3,060.59 / $5,211.01
| Facility | | $3,060.59 | $3,060.59 | $5,211.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $21,290.13
| Professional | | $2,234.23 | $2,234.23 | $21,290.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,108.65 / $2,753.46 / $3,589.32
| Professional | | $2,108.65 | $2,753.46 | $3,589.32 |