- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,165.85 / $2,208.32 / $2,208.32
| Facility | | $2,165.85 | $2,208.32 | $2,208.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.39 / $2,208.32 / $3,793.86
| Professional | | $2,123.39 | $2,208.32 | $3,793.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,037.01 / $4,587.55 / $4,587.55
| Professional | | $3,037.01 | $4,587.55 | $4,587.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,583.30 / $3,578.08 / $3,578.08
| Facility | | $2,583.30 | $3,578.08 | $3,578.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $3,578.08
| Professional | | $2,612.00 | $2,612.00 | $3,578.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,286.71 / $25,854.57 / $30,607.53
| Facility | | $8,286.71 | $25,854.57 | $30,607.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45,109.85 / $46,192.50 / $46,192.50
| Professional | | $45,109.85 | $46,192.50 | $46,192.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.32 / $2,542.96 / $3,632.67
| Professional | | $1,695.32 | $2,542.96 | $3,632.67 |