- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,890.84 / $1,927.92 / $1,927.92
| Facility | | $1,890.84 | $1,927.92 | $1,927.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.84 / $1,927.92 / $3,312.12
| Professional | | $1,890.84 | $1,927.92 | $3,312.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,651.38 / $4,005.05 / $4,450.05
| Professional | | $2,651.38 | $4,005.05 | $4,450.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $3,600.52 / $3,600.52
| Facility | | $3,600.52 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,060.44 / $3,600.52
| Professional | | $3,060.44 | $3,060.44 | $3,600.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,451.93 / $21,186.55 / $22,238.84
| Facility | | $7,451.93 | $21,186.55 | $22,238.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,846.16 / $23,846.16 / $37,259.62
| Professional | | $23,846.16 | $23,846.16 | $37,259.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.05 / $2,220.08 / $3,045.41
| Professional | | $1,480.05 | $2,220.08 | $3,045.41 |