- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,865.43 / $1,902.01 / $1,902.01
| Facility | | $1,865.43 | $1,902.01 | $1,902.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.43 / $1,902.01 / $3,267.61
| Professional | | $1,865.43 | $1,902.01 | $3,267.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,615.75 / $3,951.23 / $3,951.23
| Professional | | $2,615.75 | $3,951.23 | $3,951.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.42 / $2,728.17 / $2,728.17
| Facility | | $2,119.42 | $2,728.17 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $2,728.17
| Professional | | $1,991.56 | $1,991.56 | $2,728.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,859.76 / $20,802.65 / $22,879.56
| Facility | | $6,859.76 | $20,802.65 | $22,879.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,201.14 / $24,201.14 / $29,750.55
| Professional | | $24,201.14 | $24,201.14 | $29,750.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.16 / $2,190.25 / $2,980.36
| Professional | | $1,460.16 | $2,190.25 | $2,980.36 |