- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,183.27 / $3,183.27 / $3,183.27
| Facility | | $3,183.27 | $3,183.27 | $3,183.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.01 / $2,216.19 / $3,545.92
| Professional | | $1,277.01 | $2,216.19 | $3,545.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,742.32 / $3,951.45 / $4,330.88
| Facility | | $3,742.32 | $3,951.45 | $4,330.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,093.30 / $4,093.30 / $4,093.30
| Professional | | $4,093.30 | $4,093.30 | $4,093.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $2,728.17
| Facility | | $2,728.17 | $2,728.17 | $2,728.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $6,359.06
| Professional | | $1,991.56 | $1,991.56 | $6,359.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.01 / $3,411.81 / $20,802.65
| Facility | | $1,277.01 | $3,411.81 | $20,802.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.72 / $2,423.96 / $5,408.47
| Professional | | $1,318.72 | $2,423.96 | $5,408.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.01 / $2,112.02 / $3,048.16
| Professional | | $1,408.01 | $2,112.02 | $3,048.16 |