- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,045.67 / $1,066.18 / $1,066.18
| Facility | | $1,045.67 | $1,066.18 | $1,066.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.83 / $1,066.18 / $1,831.67
| Professional | | $1,043.83 | $1,066.18 | $1,831.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.27 / $2,214.87 / $2,214.87
| Professional | | $1,466.27 | $2,214.87 | $2,214.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.32 / $1,366.32 / $1,366.32
| Facility | | $1,366.32 | $1,366.32 | $1,366.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.41 / $997.41 / $1,366.32
| Professional | | $997.41 | $997.41 | $1,366.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,322.31 / $11,410.07 / $11,410.07
| Facility | | $3,322.31 | $11,410.07 | $11,410.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,323.41 / $12,323.41 / $17,917.73
| Professional | | $12,323.41 | $12,323.41 | $17,917.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.50 / $1,227.75 / $1,643.61
| Professional | | $818.50 | $1,227.75 | $1,643.61 |