- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,213.51 / $1,237.31 / $1,237.31
| Facility | | $1,213.51 | $1,237.31 | $1,237.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.51 / $1,302.17 / $2,125.67
| Professional | | $1,213.51 | $1,302.17 | $2,125.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.62 / $2,570.37 / $2,570.37
| Professional | | $1,701.62 | $2,570.37 | $2,570.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.62 / $2,050.41 / $2,050.41
| Facility | | $1,526.62 | $2,050.41 | $2,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $2,050.41
| Professional | | $1,496.80 | $1,496.80 | $2,050.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,837.59 / $15,093.28 / $18,087.81
| Facility | | $4,837.59 | $15,093.28 | $18,087.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,918.90 / $19,372.95 / $23,832.68
| Professional | | $18,918.90 | $19,372.95 | $23,832.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.88 / $1,424.81 / $2,146.75
| Professional | | $949.88 | $1,424.81 | $2,146.75 |