- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,153.08 / $1,175.69 / $1,175.69
| Facility | | $1,153.08 | $1,175.69 | $1,175.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.78 / $1,175.69 / $2,019.81
| Professional | | $1,148.78 | $1,175.69 | $2,019.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.87 / $2,442.37 / $2,442.37
| Professional | | $1,616.87 | $2,442.37 | $2,442.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.94 / $1,482.94 / $1,482.94
| Facility | | $1,482.94 | $1,482.94 | $1,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,260.50 / $1,482.94
| Professional | | $1,260.50 | $1,260.50 | $1,482.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,240.22 / $11,409.47 / $12,757.93
| Facility | | $4,240.22 | $11,409.47 | $12,757.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,194.36 / $13,194.36 / $19,538.40
| Professional | | $13,194.36 | $13,194.36 | $19,538.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.57 / $1,353.86 / $1,789.04
| Professional | | $902.57 | $1,353.86 | $1,789.04 |