- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,796.51 / $1,831.74 / $1,831.74
| Facility | | $1,796.51 | $1,831.74 | $1,831.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.36 / $1,831.74 / $3,146.89
| Professional | | $1,670.36 | $1,831.74 | $3,146.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,519.11 / $3,805.23 / $3,805.23
| Professional | | $2,519.11 | $3,805.23 | $3,805.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $3,297.39
| Facility | | $3,297.39 | $3,297.39 | $3,297.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $2,407.09 / $3,297.39
| Professional | | $2,407.09 | $2,407.09 | $3,297.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,677.48 / $19,929.31 / $24,212.22
| Facility | | $6,677.48 | $19,929.31 | $24,212.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,066.71 / $30,788.33 / $30,788.33
| Professional | | $30,066.71 | $30,788.33 | $30,788.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.22 / $2,109.32 / $2,909.81
| Professional | | $1,406.22 | $2,109.32 | $2,909.81 |