- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,556.03 / $2,556.03 / $2,556.03
| Facility | | $2,556.03 | $2,556.03 | $2,556.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,644.60 / $3,556.74 / $4,482.93
| Professional | | $2,644.60 | $3,556.74 | $4,482.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,873.00 / $12,904.00 / $26,880.01
| Facility | | $8,873.00 | $12,904.00 | $26,880.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.09 / $2,506.69 / $3,463.49
| Professional | | $1,201.09 | $2,506.69 | $3,463.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,346.67 / $2,466.00 / $2,518.00
| Facility | | $2,346.67 | $2,466.00 | $2,518.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.17 / $1,923.34 / $2,408.73
| Professional | | $1,162.17 | $1,923.34 | $2,408.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.20 / $2,332.59 / $3,950.40
| Professional | | $1,196.20 | $2,332.59 | $3,950.40 |