- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.01 / $1,277.01 / $1,277.01
| Facility | | $1,277.01 | $1,277.01 | $1,277.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.01 / $1,560.56 / $13,897.50
| Professional | | $1,277.01 | $1,560.56 | $13,897.50 |
- 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 / $5,138.12
| Professional | | $1,991.56 | $1,991.56 | $5,138.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.21 / $2,894.53 / $3,762.88
| Professional | | $1,801.21 | $2,894.53 | $3,762.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,471.87 / $3,872.04 / $3,872.04
| Facility | | $3,471.87 | $3,872.04 | $3,872.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,204.87 / $2,775.48 / $4,163.22
| Professional | | $2,204.87 | $2,775.48 | $4,163.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.03 / $1,978.08 / $2,837.81
| Professional | | $1,786.03 | $1,978.08 | $2,837.81 |