- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.67 / $1,434.25 / $1,434.25
| Facility | | $1,406.67 | $1,434.25 | $1,434.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.67 / $1,542.49 / $2,473.32
| Professional | | $1,406.67 | $1,542.49 | $2,473.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.47 / $2,979.51 / $2,979.51
| Professional | | $1,972.47 | $2,979.51 | $2,979.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.62 / $2,482.86 / $2,482.86
| Facility | | $1,769.62 | $2,482.86 | $2,482.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.49 / $1,812.49 / $2,482.86
| Professional | | $1,812.49 | $1,812.49 | $2,482.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,665.02 / $17,674.86 / $20,966.93
| Facility | | $5,665.02 | $17,674.86 | $20,966.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,536.86 / $23,077.76 / $26,583.68
| Professional | | $22,536.86 | $23,077.76 | $26,583.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.54 / $2,182.50 / $2,545.08
| Facility | | $1,272.54 | $2,182.50 | $2,545.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.07 / $1,651.61 / $2,488.46
| Professional | | $1,101.07 | $1,651.61 | $2,488.46 |