- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,688.25 / $1,721.35 / $1,721.35
| Facility | | $1,688.25 | $1,721.35 | $1,721.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.25 / $1,721.35 / $2,957.24
| Professional | | $1,688.25 | $1,721.35 | $2,957.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.30 / $3,575.92 / $3,973.24
| Professional | | $2,367.30 | $3,575.92 | $3,973.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $3,214.74
| Facility | | $3,214.74 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $2,732.53 / $3,214.74
| Professional | | $2,732.53 | $2,732.53 | $3,214.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,653.52 / $18,916.50 / $19,856.05
| Facility | | $6,653.52 | $18,916.50 | $19,856.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21,291.26 / $21,291.26 / $33,267.60
| Professional | | $21,291.26 | $21,291.26 | $33,267.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.47 / $1,982.21 / $2,719.10
| Professional | | $1,321.47 | $1,982.21 | $2,719.10 |