- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.14 / $1,541.14 / $3,962.92
| Facility | | $1,541.14 | $1,541.14 | $3,962.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.14 / $1,541.14 / $2,069.53
| Professional | | $1,541.14 | $1,541.14 | $2,069.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,660.08 / $4,436.26 / $4,978.42
| Professional | | $3,660.08 | $4,436.26 | $4,978.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $2,554.92 / $3,212.62
| Professional | | $2,529.63 | $2,554.92 | $3,212.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.14 / $2,619.94 / $10,457.70
| Facility | | $1,541.14 | $2,619.94 | $10,457.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $2,201.62 / $3,742.75
| Professional | | $924.68 | $2,201.62 | $3,742.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $2,245.65 / $3,192.35
| Professional | | $924.68 | $2,245.65 | $3,192.35 |