- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,771.67 / $1,806.41 / $1,806.41
| Facility | | $1,771.67 | $1,806.41 | $1,806.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,771.67 / $1,825.52 / $3,103.38
| Professional | | $1,771.67 | $1,825.52 | $3,103.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,484.28 / $3,752.62 / $3,752.62
| Professional | | $2,484.28 | $3,752.62 | $3,752.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,228.80 / $3,006.81 / $3,006.81
| Facility | | $2,228.80 | $3,006.81 | $3,006.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $2,194.96 / $3,006.81
| Professional | | $2,194.96 | $2,194.96 | $3,006.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,622.31 / $22,146.98 / $26,407.34
| Facility | | $7,622.31 | $22,146.98 | $26,407.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27,149.58 / $27,801.18 / $38,111.55
| Professional | | $27,149.58 | $27,801.18 | $38,111.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.78 / $2,080.16 / $3,134.16
| Professional | | $1,386.78 | $2,080.16 | $3,134.16 |