- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,420.87 / $1,420.87 / $1,420.87
| Facility | | $1,420.87 | $1,420.87 | $1,420.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.87 / $1,645.62 / $13,903.50
| Professional | | $1,420.87 | $1,645.62 | $13,903.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $2,756.64
| Facility | | $2,756.64 | $2,756.64 | $2,756.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.35 / $2,012.35 / $5,780.86
| Professional | | $2,012.35 | $2,012.35 | $5,780.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.68 / $3,651.10 / $4,746.43
| Professional | | $2,263.68 | $3,651.10 | $4,746.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,379.35 / $4,884.12 / $4,884.12
| Facility | | $4,379.35 | $4,884.12 | $4,884.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,781.19 / $3,500.94 / $5,251.41
| Professional | | $2,781.19 | $3,500.94 | $5,251.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.29 / $2,200.91 / $2,818.06
| Professional | | $1,723.29 | $2,200.91 | $2,818.06 |