- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,328.19 / $2,373.84 / $2,373.84
| Facility | | $2,328.19 | $2,373.84 | $2,373.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,328.19 / $2,373.84 / $4,078.22
| Professional | | $2,328.19 | $2,373.84 | $4,078.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,264.64 / $4,931.41 / $4,931.41
| Professional | | $3,264.64 | $4,931.41 | $4,931.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,852.74 / $4,072.36 / $4,072.36
| Facility | | $2,852.74 | $4,072.36 | $4,072.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.82 / $2,972.82 / $4,072.36
| Professional | | $2,972.82 | $2,972.82 | $4,072.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,175.74 / $28,628.31 / $33,799.96
| Facility | | $9,175.74 | $28,628.31 | $33,799.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40,587.48 / $41,561.60 / $44,265.60
| Professional | | $40,587.48 | $41,561.60 | $44,265.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.39 / $2,733.58 / $4,011.56
| Professional | | $1,822.39 | $2,733.58 | $4,011.56 |