- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,108.41 / $2,149.75 / $2,149.75
| Facility | | $2,108.41 | $2,149.75 | $2,149.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.29 / $2,149.75 / $3,693.23
| Professional | | $2,096.29 | $2,149.75 | $3,693.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,956.47 / $4,465.88 / $4,465.88
| Professional | | $2,956.47 | $4,465.88 | $4,465.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.92 / $2,801.20 / $2,801.20
| Facility | | $2,574.92 | $2,801.20 | $2,801.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $2,801.20
| Professional | | $2,044.88 | $2,044.88 | $2,801.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,698.82 / $22,982.54 / $22,982.54
| Facility | | $6,698.82 | $22,982.54 | $22,982.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,847.51 / $24,847.51 / $36,128.18
| Professional | | $24,847.51 | $24,847.51 | $36,128.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.36 / $2,475.53 / $3,314.06
| Professional | | $1,650.36 | $2,475.53 | $3,314.06 |