- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,599.35 / $1,630.71 / $1,630.71
| Facility | | $1,599.35 | $1,630.71 | $1,630.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.13 / $1,630.71 / $2,801.54
| Professional | | $1,590.13 | $1,630.71 | $2,801.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,242.64 / $3,387.65 / $3,387.65
| Professional | | $2,242.64 | $3,387.65 | $3,387.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,953.19 / $2,264.80 / $2,264.80
| Facility | | $1,953.19 | $2,264.80 | $2,264.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $1,653.30 / $2,264.80
| Professional | | $1,653.30 | $1,653.30 | $2,264.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,081.47 / $17,433.41 / $17,433.41
| Facility | | $5,081.47 | $17,433.41 | $17,433.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,848.34 / $18,848.34 / $27,404.93
| Professional | | $18,848.34 | $18,848.34 | $27,404.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.89 / $1,877.84 / $2,513.88
| Professional | | $1,251.89 | $1,877.84 | $2,513.88 |