- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,648.76 / $1,864.20 / $6,001.50
| Facility | | $1,648.76 | $1,864.20 | $6,001.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.76 / $1,714.71 / $1,868.60
| Professional | | $1,648.76 | $1,714.71 | $1,868.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.14 / $3,077.69 / $4,330.75
| Professional | | $1,143.14 | $3,077.69 | $4,330.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,472.12 / $4,736.24 / $7,849.76
| Facility | | $1,472.12 | $4,736.24 | $7,849.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,198.35 / $2,198.35 / $10,596.05
| Professional | | $2,198.35 | $2,198.35 | $10,596.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,825.13 / $10,442.16 / $10,442.16
| Facility | | $3,825.13 | $10,442.16 | $10,442.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,947.78 / $10,947.78 / $16,487.63
| Professional | | $10,947.78 | $10,947.78 | $16,487.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $1,319.01 / $2,198.35
| Professional | | $923.31 | $1,319.01 | $2,198.35 |