- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,488.48 / $1,517.66 / $1,517.66
| Facility | | $1,488.48 | $1,517.66 | $1,517.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.48 / $1,517.66 / $2,607.32
| Professional | | $1,488.48 | $1,517.66 | $2,607.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,087.17 / $3,152.78 / $3,152.78
| Professional | | $2,087.17 | $3,152.78 | $3,152.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,813.42 / $2,782.58 / $2,782.58
| Facility | | $1,813.42 | $2,782.58 | $2,782.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.28 / $2,031.28 / $2,782.58
| Professional | | $2,031.28 | $2,031.28 | $2,782.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,702.10 / $17,790.55 / $18,435.41
| Facility | | $5,702.10 | $17,790.55 | $18,435.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20,910.48 / $20,910.48 / $25,972.65
| Professional | | $20,910.48 | $20,910.48 | $25,972.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.09 / $1,747.65 / $2,550.06
| Professional | | $1,165.09 | $1,747.65 | $2,550.06 |