- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,142.07 / $1,142.07 / $1,142.07
| Facility | | $1,142.07 | $1,142.07 | $1,142.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.96 / $1,142.07 / $1,142.07
| Professional | | $1,086.96 | $1,142.07 | $1,142.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.82 / $2,263.82 / $2,263.82
| Professional | | $2,263.82 | $2,263.82 | $2,263.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.91 / $1,887.32 / $3,059.92
| Facility | | $1,395.91 | $1,887.32 | $3,059.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.11 / $2,331.67 / $8,706.79
| Professional | | $1,330.11 | $2,331.67 | $8,706.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,598.28 / $2,320.42 / $10,724.19
| Facility | | $1,598.28 | $2,320.42 | $10,724.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.28 / $2,320.42 / $2,331.67
| Professional | | $1,598.28 | $2,320.42 | $2,331.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.11 / $2,182.67 / $3,395.28
| Professional | | $1,330.11 | $2,182.67 | $3,395.28 |