- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,109.53 / $1,109.53 / $1,109.53
| Facility | | $1,109.53 | $1,109.53 | $1,109.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.53 / $1,731.30 / $10,859.80
| Professional | | $1,109.53 | $1,731.30 | $10,859.80 |
- 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 / $2,480.44
| Professional | | $1,698.53 | $2,326.75 | $2,480.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.57 / $2,846.09 / $3,699.91
| Professional | | $1,764.57 | $2,846.09 | $3,699.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,413.77 / $3,807.25 / $3,807.25
| Facility | | $3,413.77 | $3,807.25 | $3,807.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,167.98 / $2,729.03 / $4,093.55
| Professional | | $2,167.98 | $2,729.03 | $4,093.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.70 / $1,703.33 / $2,018.54
| Professional | | $1,345.70 | $1,703.33 | $2,018.54 |