- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.66 / $1,240.52 / $1,240.52
| Facility | | $1,216.66 | $1,240.52 | $1,240.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.46 / $1,240.52 / $2,131.19
| Professional | | $998.46 | $1,240.52 | $2,131.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.54 / $2,147.54 / $2,147.54
| Professional | | $2,147.54 | $2,147.54 | $2,147.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.03 / $2,577.04 / $2,577.04
| Professional | | $1,706.03 | $2,577.04 | $2,577.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,221.52 / $1,800.00 / $1,800.00
| Facility | | $1,221.52 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.00 / $1,314.00 / $1,800.00
| Professional | | $1,314.00 | $1,314.00 | $1,800.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,865.56 / $11,959.60 / $11,959.60
| Facility | | $3,865.56 | $11,959.60 | $11,959.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,435.44 / $14,435.44 / $17,138.93
| Professional | | $14,435.44 | $14,435.44 | $17,138.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.05 / $1,428.51 / $1,756.79
| Professional | | $950.05 | $1,428.51 | $1,756.79 |