- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.57 / $1,470.57 / $1,470.57
| Facility | | $1,470.57 | $1,470.57 | $1,470.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.57 / $1,972.39 / $17,565.09
| Professional | | $1,470.57 | $1,972.39 | $17,565.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $2,853.06
| Facility | | $2,853.06 | $2,853.06 | $2,853.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $3,510.17
| Professional | | $2,082.73 | $2,853.06 | $3,510.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,765.62 / $4,444.32 / $5,777.61
| Professional | | $2,765.62 | $4,444.32 | $5,777.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,330.78 / $5,945.21 / $5,945.21
| Facility | | $5,330.78 | $5,945.21 | $5,945.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,385.41 / $4,261.53 / $6,392.30
| Professional | | $3,385.41 | $4,261.53 | $6,392.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.73 / $2,277.89 / $3,267.93
| Professional | | $2,056.73 | $2,277.89 | $3,267.93 |