- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.60 / $1,202.74 / $1,202.74
| Facility | | $1,179.60 | $1,202.74 | $1,202.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.55 / $1,202.74 / $2,066.29
| Professional | | $1,177.55 | $1,202.74 | $2,066.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.07 / $2,498.57 / $2,498.57
| Professional | | $1,654.07 | $2,498.57 | $2,498.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.24 / $1,786.24 / $1,786.24
| Facility | | $1,786.24 | $1,786.24 | $1,786.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,303.96 / $1,786.24
| Professional | | $1,303.96 | $1,303.96 | $1,786.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,747.86 / $12,858.35 / $12,858.35
| Facility | | $3,747.86 | $12,858.35 | $12,858.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,901.92 / $13,901.92 / $20,213.09
| Professional | | $13,901.92 | $13,901.92 | $20,213.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.34 / $1,385.01 / $1,854.16
| Professional | | $923.34 | $1,385.01 | $1,854.16 |