- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,833.14 / $1,833.14 / $2,701.79
| Facility | | $1,833.14 | $1,833.14 | $2,701.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,765.24 / $1,833.14 / $2,069.05
| Professional | | $1,765.24 | $1,833.14 | $2,069.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,394.70 / $3,394.70 / $3,394.70
| Professional | | $3,394.70 | $3,394.70 | $3,394.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,326.75
| Facility | | $2,326.75 | $2,326.75 | $2,326.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $2,326.75 / $2,326.75
| Professional | | $1,698.53 | $2,326.75 | $2,326.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,109.53 / $2,360.76 / $17,957.82
| Facility | | $1,109.53 | $2,360.76 | $17,957.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.77 / $1,847.89 / $3,834.36
| Professional | | $1,145.77 | $1,847.89 | $3,834.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.77 / $1,718.66 / $2,465.63
| Professional | | $1,145.77 | $1,718.66 | $2,465.63 |