- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.23 / $1,002.23 / $2,573.28
| Facility | | $1,002.23 | $1,002.23 | $2,573.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.23 / $1,292.70 / $2,573.28
| Professional | | $1,002.23 | $1,292.70 | $2,573.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,093.43 / $3,093.43 / $3,093.43
| Facility | | $3,093.43 | $3,093.43 | $3,093.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,456.62 / $1,481.65 / $3,233.67
| Professional | | $1,456.62 | $1,481.65 | $3,233.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.38 / $1,769.38 / $2,277.33
| Facility | | $1,769.38 | $1,769.38 | $2,277.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,769.38 / $2,044.46
| Professional | | $1,291.65 | $1,769.38 | $2,044.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,720.24 / $2,474.73 / $4,021.46
| Professional | | $1,720.24 | $2,474.73 | $4,021.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.36 / $1,209.93 / $2,016.55
| Professional | | $947.36 | $1,209.93 | $2,016.55 |