- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,402.83 / $1,430.34 / $1,430.34
| Facility | | $1,402.83 | $1,430.34 | $1,430.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.42 / $1,430.34 / $2,457.29
| Professional | | $1,286.42 | $1,430.34 | $2,457.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,476.14 / $2,476.14 / $2,476.14
| Professional | | $2,476.14 | $2,476.14 | $2,476.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.07 / $2,971.37 / $2,971.37
| Professional | | $1,967.07 | $2,971.37 | $2,971.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.08 / $1,721.98 / $1,721.98
| Facility | | $1,473.08 | $1,721.98 | $1,721.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.05 / $1,257.05 / $1,721.98
| Professional | | $1,257.05 | $1,257.05 | $1,721.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,158.62 / $14,785.52 / $17,378.68
| Facility | | $5,158.62 | $14,785.52 | $17,378.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,561.62 / $17,575.11 / $20,668.43
| Professional | | $17,561.62 | $17,575.11 | $20,668.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.06 / $1,647.10 / $2,156.88
| Professional | | $1,098.06 | $1,647.10 | $2,156.88 |