- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,233.28 / $2,233.28 / $2,440.06
| Facility | | $2,233.28 | $2,233.28 | $2,440.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,097.06 / $2,303.46 / $4,180.04
| Professional | | $2,097.06 | $2,303.46 | $4,180.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,957.57 / $4,467.56 / $4,467.56
| Professional | | $2,957.57 | $4,467.56 | $4,467.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $2,756.64
| Professional | | $2,012.35 | $2,012.35 | $2,756.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,756.19 / $22,996.26 / $22,996.26
| Facility | | $7,756.19 | $22,996.26 | $22,996.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,906.67 / $24,906.67 / $36,141.23
| Professional | | $24,906.67 | $24,906.67 | $36,141.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.98 / $2,373.09 / $3,272.50
| Professional | | $1,650.98 | $2,373.09 | $3,272.50 |