- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.91 / $1,342.91 / $1,342.91
| Facility | | $1,342.91 | $1,342.91 | $1,342.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.91 / $1,801.18 / $16,040.40
| Professional | | $1,342.91 | $1,801.18 | $16,040.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,006.81 / $3,006.81
| Facility | | $3,006.81 | $3,006.81 | $3,006.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $3,006.81 / $3,097.01
| Professional | | $2,194.96 | $3,006.81 | $3,097.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.27 / $3,339.16 / $4,340.90
| Professional | | $2,070.27 | $3,339.16 | $4,340.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,005.20 / $4,466.84 / $4,466.84
| Facility | | $4,005.20 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,543.58 / $3,201.83 / $4,802.74
| Professional | | $2,543.58 | $3,201.83 | $4,802.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.20 / $2,080.16 / $2,984.25
| Professional | | $1,878.20 | $2,080.16 | $2,984.25 |