- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,527.58 / $1,557.53 / $1,557.53
| Facility | | $1,527.58 | $1,557.53 | $1,557.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.58 / $1,573.86 / $2,708.74
| Professional | | $1,527.58 | $1,573.86 | $2,708.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,696.34 / $2,696.34 / $2,696.34
| Professional | | $2,696.34 | $2,696.34 | $2,696.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,142.00 / $3,235.61 / $3,235.61
| Professional | | $2,142.00 | $3,235.61 | $3,235.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.54 / $2,160.07 / $2,160.07
| Facility | | $1,921.54 | $2,160.07 | $2,160.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.85 / $1,576.85 / $2,160.07
| Professional | | $1,576.85 | $1,576.85 | $2,160.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,778.83 / $18,029.93 / $18,674.96
| Facility | | $5,778.83 | $18,029.93 | $18,674.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,461.27 / $19,461.27 / $27,934.13
| Professional | | $19,461.27 | $19,461.27 | $27,934.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.71 / $1,793.56 / $2,598.46
| Professional | | $1,195.71 | $1,793.56 | $2,598.46 |