- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,220.08 / $2,263.61 / $2,263.61
| Facility | | $2,220.08 | $2,263.61 | $2,263.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.08 / $2,278.19 / $4,257.17
| Professional | | $2,220.08 | $2,278.19 | $4,257.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,113.05 / $4,702.41 / $4,702.41
| Professional | | $3,113.05 | $4,702.41 | $4,702.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,792.66 / $3,745.37 / $3,745.37
| Facility | | $2,792.66 | $3,745.37 | $3,745.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $3,745.37
| Professional | | $2,734.12 | $2,734.12 | $3,745.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,802.17 / $27,462.75 / $33,025.99
| Facility | | $8,802.17 | $27,462.75 | $33,025.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34,404.35 / $35,230.05 / $39,263.18
| Professional | | $34,404.35 | $35,230.05 | $39,263.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.76 / $2,606.65 / $3,919.69
| Professional | | $1,737.76 | $2,606.65 | $3,919.69 |