- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,408.59 / $1,436.21 / $1,436.21
| Facility | | $1,408.59 | $1,436.21 | $1,436.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.59 / $1,574.31 / $2,472.33
| Professional | | $1,408.59 | $1,574.31 | $2,472.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.16 / $2,983.57 / $2,983.57
| Professional | | $1,975.16 | $2,983.57 | $2,983.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.03 / $2,637.76 / $2,637.76
| Facility | | $1,772.03 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $1,925.56 / $2,637.76
| Professional | | $1,925.56 | $1,925.56 | $2,637.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,630.17 / $17,548.22 / $20,995.52
| Facility | | $6,630.17 | $17,548.22 | $20,995.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,251.69 / $21,251.69 / $33,150.83
| Professional | | $21,251.69 | $21,251.69 | $33,150.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.57 / $1,653.86 / $2,491.86
| Professional | | $1,102.57 | $1,653.86 | $2,491.86 |