- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,093.42 / $2,134.46 / $2,134.46
| Facility | | $2,093.42 | $2,134.46 | $2,134.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,093.42 / $2,134.46 / $3,666.98
| Professional | | $2,093.42 | $2,134.46 | $3,666.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,935.45 / $4,434.13 / $4,926.81
| Professional | | $2,935.45 | $4,434.13 | $4,926.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $2,802.84
| Facility | | $2,802.84 | $2,802.84 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,382.41 / $2,802.84
| Professional | | $2,382.41 | $2,382.41 | $2,802.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,250.35 / $23,456.39 / $24,621.53
| Facility | | $8,250.35 | $23,456.39 | $24,621.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,401.10 / $26,401.10 / $41,251.73
| Professional | | $26,401.10 | $26,401.10 | $41,251.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.62 / $2,457.94 / $3,390.73
| Professional | | $1,638.62 | $2,457.94 | $3,390.73 |