- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.23 / $1,310.23 / $1,310.23
| Facility | | $1,310.23 | $1,310.23 | $1,310.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.23 / $1,569.51 / $13,977.20
| Professional | | $1,310.23 | $1,569.51 | $13,977.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,364.97 / $3,364.97 / $3,364.97
| Facility | | $3,364.97 | $3,364.97 | $3,364.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.42 / $3,364.97 / $3,587.23
| Professional | | $2,456.42 | $3,364.97 | $3,587.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,120.05 / $3,419.45 / $4,445.28
| Professional | | $2,120.05 | $3,419.45 | $4,445.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,101.49 / $4,574.24 / $4,574.24
| Facility | | $4,101.49 | $4,574.24 | $4,574.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,604.73 / $3,278.81 / $4,918.22
| Professional | | $2,604.73 | $3,278.81 | $4,918.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.48 / $2,029.53 / $2,911.62
| Professional | | $1,832.48 | $2,029.53 | $2,911.62 |