- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,556.51 / $1,556.51 / $1,556.51
| Facility | | $1,556.51 | $1,556.51 | $1,556.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.51 / $2,087.66 / $18,591.59
| Professional | | $1,556.51 | $2,087.66 | $18,591.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,578.08 / $3,578.08 / $3,578.08
| Facility | | $3,578.08 | $3,578.08 | $3,578.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,612.00 / $2,612.00 / $6,476.63
| Professional | | $2,612.00 | $2,612.00 | $6,476.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.38 / $3,528.04 / $4,586.45
| Professional | | $2,187.38 | $3,528.04 | $4,586.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,231.74 / $4,719.50 / $4,719.50
| Facility | | $4,231.74 | $4,719.50 | $4,719.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,687.45 / $3,382.94 / $5,074.41
| Professional | | $2,687.45 | $3,382.94 | $5,074.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,176.94 / $2,411.02 / $3,458.91
| Professional | | $2,176.94 | $2,411.02 | $3,458.91 |