- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.17 / $1,468.41 / $1,468.41
| Facility | | $1,440.17 | $1,468.41 | $1,468.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.17 / $1,483.94 / $2,543.71
| Professional | | $1,440.17 | $1,483.94 | $2,543.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,542.06 / $2,542.06 / $2,542.06
| Professional | | $2,542.06 | $2,542.06 | $2,542.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,019.44 / $3,050.47 / $3,050.47
| Professional | | $2,019.44 | $3,050.47 | $3,050.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,811.76 / $2,117.90 / $2,117.90
| Facility | | $1,811.76 | $2,117.90 | $2,117.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.07 / $1,546.07 / $2,117.90
| Professional | | $1,546.07 | $1,546.07 | $2,117.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,212.67 / $17,754.05 / $20,855.07
| Facility | | $6,212.67 | $17,754.05 | $20,855.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,074.59 / $21,074.59 / $31,063.35
| Professional | | $21,074.59 | $21,074.59 | $31,063.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.29 / $1,690.94 / $2,547.73
| Professional | | $1,127.29 | $1,690.94 | $2,547.73 |