- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,942.26 / $1,980.35 / $1,980.35
| Facility | | $1,942.26 | $1,980.35 | $1,980.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.87 / $1,980.35 / $3,402.20
| Professional | | $1,938.87 | $1,980.35 | $3,402.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,723.49 / $4,113.96 / $4,113.96
| Professional | | $2,723.49 | $4,113.96 | $4,113.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $2,941.06
| Facility | | $2,941.06 | $2,941.06 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $2,941.06
| Professional | | $2,146.96 | $2,146.96 | $2,941.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,170.94 / $21,171.57 / $21,171.57
| Facility | | $6,170.94 | $21,171.57 | $21,171.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,889.87 / $22,889.87 / $33,281.40
| Professional | | $22,889.87 | $22,889.87 | $33,281.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.30 / $2,280.46 / $3,052.92
| Professional | | $1,520.30 | $2,280.46 | $3,052.92 |