- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,113.38 / $1,113.38 / $1,113.38
| Facility | | $1,113.38 | $1,113.38 | $1,113.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.38 / $1,273.77 / $11,343.50
| Professional | | $1,113.38 | $1,273.77 | $11,343.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.07 / $2,160.07 / $2,160.07
| Facility | | $2,160.07 | $2,160.07 | $2,160.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.85 / $2,160.07 / $2,533.03
| Professional | | $1,576.85 | $2,160.07 | $2,533.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.98 / $2,830.62 / $3,679.80
| Professional | | $1,754.98 | $2,830.62 | $3,679.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,395.21 / $3,786.55 / $3,786.55
| Facility | | $3,395.21 | $3,786.55 | $3,786.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,156.19 / $2,714.20 / $4,071.30
| Professional | | $2,156.19 | $2,714.20 | $4,071.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.17 / $1,724.61 / $2,474.17
| Professional | | $1,557.17 | $1,724.61 | $2,474.17 |