- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,580.96 / $1,611.96 / $1,611.96
| Facility | | $1,580.96 | $1,611.96 | $1,611.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.96 / $1,620.12 / $2,824.71
| Professional | | $1,580.96 | $1,620.12 | $2,824.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.84 / $3,348.68 / $3,348.68
| Professional | | $2,216.84 | $3,348.68 | $3,348.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.03 / $2,717.61 / $2,717.61
| Facility | | $1,978.03 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $1,983.86 / $2,717.61
| Professional | | $1,983.86 | $1,983.86 | $2,717.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,238.61 / $19,464.45 / $21,500.64
| Facility | | $6,238.61 | $19,464.45 | $21,500.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24,570.97 / $24,570.97 / $27,929.93
| Professional | | $24,570.97 | $24,570.97 | $27,929.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.49 / $1,856.24 / $2,825.05
| Professional | | $1,237.49 | $1,856.24 | $2,825.05 |