- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,232.15 / $2,275.92 / $2,275.92
| Facility | | $2,232.15 | $2,275.92 | $2,275.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.15 / $2,299.98 / $3,909.98
| Professional | | $2,232.15 | $2,299.98 | $3,909.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,129.97 / $4,727.97 / $4,727.97
| Professional | | $3,129.97 | $4,727.97 | $4,727.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,808.09 / $3,943.38 / $3,943.38
| Facility | | $2,808.09 | $3,943.38 | $3,943.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,878.67 / $2,878.67 / $3,943.38
| Professional | | $2,878.67 | $2,878.67 | $3,943.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,884.40 / $27,719.31 / $33,270.94
| Facility | | $8,884.40 | $27,719.31 | $33,270.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34,789.14 / $35,624.07 / $41,956.35
| Professional | | $34,789.14 | $35,624.07 | $41,956.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.21 / $2,620.82 / $3,948.77
| Professional | | $1,747.21 | $2,620.82 | $3,948.77 |