- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.59 / $1,672.76 / $1,672.76
| Facility | | $1,640.59 | $1,672.76 | $1,672.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.59 / $1,678.50 / $3,001.94
| Professional | | $1,640.59 | $1,678.50 | $3,001.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,300.46 / $3,474.97 / $3,474.97
| Professional | | $2,300.46 | $3,474.97 | $3,474.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,946.92 / $3,141.52 / $3,141.52
| Facility | | $1,946.92 | $3,141.52 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $2,293.31 / $3,141.52
| Professional | | $2,293.31 | $2,293.31 | $3,141.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,361.82 / $18,963.50 / $23,067.66
| Facility | | $6,361.82 | $18,963.50 | $23,067.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23,310.48 / $23,310.48 / $29,065.58
| Professional | | $23,310.48 | $23,310.48 | $29,065.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.17 / $1,926.25 / $2,737.79
| Professional | | $1,284.17 | $1,926.25 | $2,737.79 |