- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,437.75 / $1,465.94 / $1,465.94
| Facility | | $1,437.75 | $1,465.94 | $1,465.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.75 / $1,593.65 / $2,518.44
| Professional | | $1,437.75 | $1,593.65 | $2,518.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.04 / $3,045.32 / $3,045.32
| Professional | | $2,016.04 | $3,045.32 | $3,045.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.71 / $2,375.33 / $2,375.33
| Facility | | $1,808.71 | $2,375.33 | $2,375.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.99 / $1,733.99 / $2,375.33
| Professional | | $1,733.99 | $1,733.99 | $2,375.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,567.97 / $16,837.56 / $16,837.56
| Facility | | $4,567.97 | $16,837.56 | $16,837.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22,332.37 / $22,332.37 / $27,465.45
| Professional | | $22,332.37 | $22,332.37 | $27,465.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.39 / $1,688.09 / $2,543.44
| Professional | | $1,125.39 | $1,688.09 | $2,543.44 |