- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,183.36 / $1,206.58 / $1,206.58
| Facility | | $1,183.36 | $1,206.58 | $1,206.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.36 / $1,318.04 / $2,072.88
| Professional | | $1,183.36 | $1,318.04 | $2,072.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.35 / $2,506.54 / $2,506.54
| Professional | | $1,659.35 | $2,506.54 | $2,506.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,488.70 / $2,125.02 / $2,125.02
| Facility | | $1,488.70 | $2,125.02 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.26 / $1,551.26 / $2,125.02
| Professional | | $1,551.26 | $1,551.26 | $2,125.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,862.25 / $14,520.96 / $17,638.56
| Facility | | $4,862.25 | $14,520.96 | $17,638.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,492.63 / $18,492.63 / $24,311.25
| Professional | | $18,492.63 | $18,492.63 | $24,311.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.28 / $1,389.43 / $2,093.44
| Professional | | $926.28 | $1,389.43 | $2,093.44 |