- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,463.89 / $1,463.89 / $1,463.89
| Facility | | $1,463.89 | $1,463.89 | $1,463.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.89 / $1,673.02 / $1,673.02
| Professional | | $1,463.89 | $1,673.02 | $1,673.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.82 / $2,987.53 / $2,987.53
| Professional | | $2,032.82 | $2,987.53 | $2,987.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $1,743.07
| Facility | | $1,743.07 | $1,743.07 | $1,743.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $3,818.25
| Professional | | $1,272.44 | $1,272.44 | $3,818.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.44 / $2,049.17 / $14,630.94
| Facility | | $898.44 | $2,049.17 | $14,630.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.78 / $1,839.02 / $3,453.89
| Professional | | $927.78 | $1,839.02 | $3,453.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.78 / $1,538.41 / $2,096.37
| Professional | | $927.78 | $1,538.41 | $2,096.37 |