- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,790.55 / $1,825.66 / $1,825.66
| Facility | | $1,790.55 | $1,825.66 | $1,825.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.55 / $1,942.72 / $3,136.45
| Professional | | $1,790.55 | $1,942.72 | $3,136.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.75 / $3,792.62 / $3,792.62
| Professional | | $2,510.75 | $3,792.62 | $3,792.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $2,741.63
| Professional | | $2,001.39 | $2,001.39 | $2,741.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,688.93 / $21,030.00 / $21,030.00
| Facility | | $5,688.93 | $21,030.00 | $21,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,812.52 / $27,812.52 / $33,481.50
| Professional | | $27,812.52 | $27,812.52 | $33,481.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.55 / $2,102.33 / $3,167.57
| Professional | | $1,401.55 | $2,102.33 | $3,167.57 |