- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,679.50 / $1,679.50 / $1,679.50
| Facility | | $1,679.50 | $1,679.50 | $1,679.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.50 / $2,252.62 / $20,060.59
| Professional | | $1,679.50 | $2,252.62 | $20,060.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $3,745.37
| Facility | | $3,745.37 | $3,745.37 | $3,745.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $6,779.25
| Professional | | $2,734.12 | $2,734.12 | $6,779.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,835.82 / $4,573.91 / $5,946.08
| Professional | | $2,835.82 | $4,573.91 | $5,946.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,486.21 / $6,118.56 / $6,118.56
| Facility | | $5,486.21 | $6,118.56 | $6,118.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,484.12 / $4,385.79 / $6,578.68
| Professional | | $3,484.12 | $4,385.79 | $6,578.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,167.94 / $2,601.52 / $3,732.22
| Professional | | $2,167.94 | $2,601.52 | $3,732.22 |