- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.16 / $1,224.71 / $1,224.71
| Facility | | $1,201.16 | $1,224.71 | $1,224.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.16 / $1,224.71 / $2,158.35
| Professional | | $1,201.16 | $1,224.71 | $2,158.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.28 / $2,544.21 / $2,544.21
| Professional | | $1,684.28 | $2,544.21 | $2,544.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $1,667.14 / $2,283.76
| Professional | | $1,667.14 | $1,667.14 | $2,283.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,515.30 / $14,087.74 / $16,970.52
| Facility | | $4,515.30 | $14,087.74 | $16,970.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18,640.13 / $19,087.47 / $20,945.48
| Professional | | $18,640.13 | $19,087.47 | $20,945.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.20 / $1,410.31 / $2,014.15
| Professional | | $940.20 | $1,410.31 | $2,014.15 |