- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.86 / $1,076.58 / $1,076.58
| Facility | | $1,055.86 | $1,076.58 | $1,076.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.86 / $1,081.40 / $2,088.88
| Professional | | $1,055.86 | $1,081.40 | $2,088.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.57 / $2,236.46 / $2,236.46
| Professional | | $1,480.57 | $2,236.46 | $2,236.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,328.31 / $1,552.76 / $1,552.76
| Facility | | $1,328.31 | $1,552.76 | $1,552.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $1,133.51 / $1,552.76
| Professional | | $1,133.51 | $1,133.51 | $1,552.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,345.68 / $13,558.52 / $13,970.56
| Facility | | $4,345.68 | $13,558.52 | $13,970.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,025.89 / $16,025.89 / $18,637.20
| Professional | | $16,025.89 | $16,025.89 | $18,637.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.48 / $1,239.72 / $1,867.88
| Professional | | $826.48 | $1,239.72 | $1,867.88 |