- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,465.11 / $1,465.11 / $1,465.11
| Facility | | $1,465.11 | $1,465.11 | $1,465.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.11 / $1,610.24 / $14,340.00
| Professional | | $1,465.11 | $1,610.24 | $14,340.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $3,294.10 / $3,511.67
| Professional | | $2,404.69 | $3,294.10 | $3,511.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,330.08 / $3,758.20 / $4,885.66
| Professional | | $2,330.08 | $3,758.20 | $4,885.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,507.80 / $5,027.38 / $5,027.38
| Facility | | $4,507.80 | $5,027.38 | $5,027.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.77 / $3,603.63 / $5,405.44
| Professional | | $2,862.77 | $3,603.63 | $5,405.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.11 / $2,269.44 / $3,247.67
| Professional | | $2,049.11 | $2,269.44 | $3,247.67 |