- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.06 / $1,038.06 / $1,038.06
| Facility | | $1,038.06 | $1,038.06 | $1,038.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.06 / $1,392.30 / $12,399.10
| Professional | | $1,038.06 | $1,392.30 | $12,399.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.34 / $2,561.34 / $2,561.34
| Facility | | $2,561.34 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $2,561.34 / $2,730.51
| Professional | | $1,869.78 | $2,561.34 | $2,730.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.86 / $2,378.82 / $3,092.46
| Professional | | $1,474.86 | $2,378.82 | $3,092.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.30 / $3,182.18 / $3,182.18
| Facility | | $2,853.30 | $3,182.18 | $3,182.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.03 / $2,280.98 / $3,421.48
| Professional | | $1,812.03 | $2,280.98 | $3,421.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.84 / $1,607.95 / $2,306.81
| Professional | | $1,451.84 | $1,607.95 | $2,306.81 |