- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,138.91 / $2,656.39 / $2,656.39
| Facility | | $2,138.91 | $2,656.39 | $2,656.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.91 / $2,656.39 / $3,622.35
| Professional | | $2,138.91 | $2,656.39 | $3,622.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.02 / $3,384.12 / $3,384.12
| Facility | | $798.02 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $3,384.12
| Professional | | $3,384.12 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,908.42 / $22,577.61 / $22,577.61
| Facility | | $7,908.42 | $22,577.61 | $22,577.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,051.83 / $24,051.83 / $34,812.83
| Professional | | $24,051.83 | $24,051.83 | $34,812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,990.00 / $4,200.00 / $4,200.00
| Professional | | $3,990.00 | $4,200.00 | $4,200.00 |