- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,754.81 / $1,789.22 / $1,789.22
| Facility | | $1,754.81 | $1,789.22 | $1,789.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.81 / $1,807.59 / $3,216.10
| Professional | | $1,754.81 | $1,807.59 | $3,216.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,097.42 / $3,097.42 / $3,097.42
| Professional | | $3,097.42 | $3,097.42 | $3,097.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.62 / $3,716.90 / $3,716.90
| Professional | | $2,460.62 | $3,716.90 | $3,716.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,207.38 / $2,550.04 / $2,550.04
| Facility | | $2,207.38 | $2,550.04 | $2,550.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $1,861.53 / $2,550.04
| Professional | | $1,861.53 | $1,861.53 | $2,550.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,775.88 / $21,140.73 / $25,846.18
| Facility | | $6,775.88 | $21,140.73 | $25,846.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26,362.41 / $26,362.41 / $31,152.60
| Professional | | $26,362.41 | $26,362.41 | $31,152.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.57 / $2,060.36 / $3,067.56
| Professional | | $1,373.57 | $2,060.36 | $3,067.56 |