- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,900.02 / $1,937.28 / $1,937.28
| Facility | | $1,900.02 | $1,937.28 | $1,937.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.02 / $2,090.50 / $3,402.72
| Professional | | $1,900.02 | $2,090.50 | $3,402.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.26 / $4,024.49 / $4,024.49
| Professional | | $2,664.26 | $4,024.49 | $4,024.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,390.26 / $3,813.78 / $3,813.78
| Facility | | $2,390.26 | $3,813.78 | $3,813.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $2,784.06 / $3,813.78
| Professional | | $2,784.06 | $2,784.06 | $3,813.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,141.22 / $23,822.60 / $28,320.45
| Facility | | $8,141.22 | $23,822.60 | $28,320.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,618.56 / $28,618.56 / $40,706.10
| Professional | | $28,618.56 | $28,618.56 | $40,706.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.24 / $2,230.86 / $3,361.22
| Professional | | $1,487.24 | $2,230.86 | $3,361.22 |