- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,201.62 / $4,678.43
| Facility | | $2,201.62 | $2,201.62 | $4,678.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.31 / $1,783.31 / $1,783.31
| Professional | | $1,783.31 | $1,783.31 | $1,783.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.34 / $12.34 / $1,431.05
| Professional | | $12.34 | $12.34 | $1,431.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $2,529.63 / $3,162.03
| Professional | | $2,529.63 | $2,529.63 | $3,162.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,201.62 / $2,666.16
| Professional | | $2,201.62 | $2,201.62 | $2,666.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,201.62 / $2,201.62 / $3,566.62
| Facility | | $2,201.62 | $2,201.62 | $3,566.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.31 / $1,783.31 / $2,201.62
| Professional | | $1,783.31 | $1,783.31 | $2,201.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.97 / $1,320.97 / $3,192.35
| Professional | | $1,320.97 | $1,320.97 | $3,192.35 |