- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.25 / $1,066.25 / $1,066.25
| Facility | | $1,066.25 | $1,066.25 | $1,066.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.25 / $1,430.10 / $12,735.70
| Professional | | $1,066.25 | $1,430.10 | $12,735.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.86 / $2,482.86 / $2,482.86
| Facility | | $2,482.86 | $2,482.86 | $2,482.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.49 / $2,482.86 / $2,646.85
| Professional | | $1,812.49 | $2,482.86 | $2,646.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.25 / $2,640.68 / $3,432.88
| Professional | | $1,643.25 | $2,640.68 | $3,432.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,167.39 / $3,532.47 / $3,532.47
| Facility | | $3,167.39 | $3,532.47 | $3,532.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.51 / $2,532.08 / $3,798.11
| Professional | | $2,011.51 | $2,532.08 | $3,798.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,376.34 / $2,202.14 / $2,488.46
| Facility | | $1,376.34 | $2,202.14 | $2,488.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.19 / $1,651.61 / $2,369.44
| Professional | | $1,293.19 | $1,651.61 | $2,369.44 |