- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.21 / $1,489.86 / $1,489.86
| Facility | | $1,461.21 | $1,489.86 | $1,489.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.21 / $1,489.86 / $2,733.48
| Professional | | $1,461.21 | $1,489.86 | $2,733.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,579.19 / $2,579.19 / $3,438.92
| Professional | | $2,579.19 | $2,579.19 | $3,438.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.94 / $3,095.03 / $3,095.03
| Professional | | $2,048.94 | $3,095.03 | $3,095.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,789.71 / $2,400.00 / $2,400.00
| Facility | | $1,789.71 | $2,400.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.00 / $1,752.00 / $2,400.00
| Professional | | $1,752.00 | $1,752.00 | $2,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,473.65 / $17,077.79 / $20,817.16
| Facility | | $5,473.65 | $17,077.79 | $20,817.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,693.67 / $21,693.67 / $25,111.05
| Professional | | $21,693.67 | $21,693.67 | $25,111.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.76 / $1,715.64 / $2,470.67
| Professional | | $1,143.76 | $1,715.64 | $2,470.67 |