- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.26 / $1,454.26 / $1,454.26
| Facility | | $1,454.26 | $1,454.26 | $1,454.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.25 / $1,454.26 / $1,677.57
| Professional | | $1,454.25 | $1,454.26 | $1,677.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,881.00 / $2,881.00 / $2,881.00
| Professional | | $2,881.00 | $2,881.00 | $2,881.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.80 / $2,967.88 / $2,967.88
| Professional | | $2,419.80 | $2,967.88 | $2,967.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.90 / $2,117.90 / $2,117.90
| Facility | | $2,117.90 | $2,117.90 | $2,117.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.07 / $1,546.07 / $4,123.88
| Professional | | $1,546.07 | $1,546.07 | $4,123.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.64 / $2,035.69 / $17,754.05
| Facility | | $1,091.64 | $2,035.69 | $17,754.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.29 / $2,234.46 / $3,431.16
| Professional | | $1,127.29 | $2,234.46 | $3,431.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.29 / $1,620.35 / $2,547.16
| Professional | | $1,127.29 | $1,620.35 | $2,547.16 |