- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,691.53 / $3,467.37
| Professional | | $1,380.38 | $2,691.53 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,762.47 / $7,943.28
| Facility | | $7,079.46 | $7,762.47 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $7,585.78 / $7,585.78
| Professional | | $5,248.07 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,715.35
| Professional | | $3,467.37 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $588.84 / $3,715.35
| Facility | | $295.12 | $588.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,548.13 / $5,248.07
| Professional | | $1,819.70 | $3,548.13 | $5,248.07 |