- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,997.58 / $2,036.75 / $2,036.75
| Facility | | $1,997.58 | $2,036.75 | $2,036.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.58 / $2,058.30 / $3,825.37
| Professional | | $1,997.58 | $2,058.30 | $3,825.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,801.06 / $4,231.13 / $4,231.13
| Professional | | $2,801.06 | $4,231.13 | $4,231.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,513.00 / $3,798.08 / $3,798.08
| Facility | | $2,513.00 | $3,798.08 | $3,798.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.60 / $2,772.60 / $3,798.08
| Professional | | $2,772.60 | $2,772.60 | $3,798.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,402.53 / $24,802.46 / $29,550.18
| Facility | | $9,402.53 | $24,802.46 | $29,550.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31,028.33 / $31,028.33 / $47,012.63
| Professional | | $31,028.33 | $31,028.33 | $47,012.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.60 / $2,345.41 / $3,533.81
| Professional | | $1,563.60 | $2,345.41 | $3,533.81 |