- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,213.22 / $1,237.01 / $1,237.01
| Facility | | $1,213.22 | $1,237.01 | $1,237.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.22 / $1,358.86 / $2,301.44
| Professional | | $1,213.22 | $1,358.86 | $2,301.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.21 / $2,569.76 / $2,569.76
| Professional | | $1,701.21 | $2,569.76 | $2,569.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.26 / $1,784.15 / $1,784.15
| Facility | | $1,526.26 | $1,784.15 | $1,784.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.43 / $1,302.43 / $1,784.15
| Professional | | $1,302.43 | $1,302.43 | $1,784.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,323.44 / $15,230.69 / $17,614.71
| Facility | | $5,323.44 | $15,230.69 | $17,614.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,819.31 / $17,819.31 / $26,617.20
| Professional | | $17,819.31 | $17,819.31 | $26,617.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.65 / $1,424.47 / $2,195.07
| Professional | | $949.65 | $1,424.47 | $2,195.07 |