- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,030.27 / $1,050.47 / $1,050.47
| Facility | | $1,030.27 | $1,050.47 | $1,050.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.46 / $1,050.47 / $1,804.69
| Professional | | $1,028.46 | $1,050.47 | $1,804.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.67 / $2,182.23 / $2,182.23
| Professional | | $1,444.67 | $2,182.23 | $2,182.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.22 / $1,346.19 / $1,346.19
| Facility | | $1,258.22 | $1,346.19 | $1,346.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.72 / $982.72 / $1,346.19
| Professional | | $982.72 | $982.72 | $1,346.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,273.35 / $11,271.87 / $11,271.87
| Facility | | $3,273.35 | $11,271.87 | $11,271.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,141.34 / $12,141.34 / $17,653.95
| Professional | | $12,141.34 | $12,141.34 | $17,653.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.44 / $1,209.66 / $1,656.24
| Professional | | $806.44 | $1,209.66 | $1,656.24 |