- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,413.82 / $1,441.54 / $1,441.54
| Facility | | $1,413.82 | $1,441.54 | $1,441.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.82 / $1,441.54 / $2,476.53
| Professional | | $1,413.82 | $1,441.54 | $2,476.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.48 / $2,994.64 / $2,994.64
| Professional | | $1,982.48 | $2,994.64 | $2,994.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,722.35 / $2,425.11 / $2,425.11
| Facility | | $1,722.35 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $1,770.33 / $2,425.11
| Professional | | $1,770.33 | $1,770.33 | $2,425.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,491.96 / $16,380.05 / $16,380.05
| Facility | | $4,491.96 | $16,380.05 | $16,380.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,267.33 / $19,267.33 / $24,191.25
| Professional | | $19,267.33 | $19,267.33 | $24,191.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.66 / $1,660.00 / $2,373.58
| Professional | | $1,106.66 | $1,660.00 | $2,373.58 |