- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,538.66 / $1,538.66 / $1,538.66
| Facility | | $1,538.66 | $1,538.66 | $1,538.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.66 / $2,262.56 / $3,484.42
| Professional | | $1,538.66 | $2,262.56 | $3,484.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $434.63 / $869.27 / $5,491.22
| Facility | | $434.63 | $869.27 | $5,491.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,290.01 / $4,290.01 / $4,290.01
| Facility | | $4,290.01 | $4,290.01 | $4,290.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.00 / $1,700.00 / $17,645.09
| Professional | | $1,700.00 | $1,700.00 | $17,645.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.54 / $2,887.69 / $5,125.13
| Professional | | $1,978.54 | $2,887.69 | $5,125.13 |