- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,940.08 / $1,978.12 / $1,978.12
| Facility | | $1,940.08 | $1,978.12 | $1,978.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.08 / $1,987.00 / $3,398.37
| Professional | | $1,940.08 | $1,987.00 | $3,398.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,720.42 / $4,109.33 / $4,109.33
| Professional | | $2,720.42 | $4,109.33 | $4,109.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,440.66 / $2,853.06 / $2,853.06
| Facility | | $2,440.66 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,082.73 / $2,853.06
| Professional | | $2,082.73 | $2,082.73 | $2,853.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,811.46 / $24,371.76 / $28,917.53
| Facility | | $7,811.46 | $24,371.76 | $28,917.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,317.74 / $30,317.74 / $34,244.40
| Professional | | $30,317.74 | $30,317.74 | $34,244.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.59 / $2,277.89 / $3,432.08
| Professional | | $1,518.59 | $2,277.89 | $3,432.08 |