- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,173.07 / $1,173.07 / $1,173.07
| Facility | | $1,173.07 | $1,173.07 | $1,173.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.07 / $1,573.38 / $14,011.70
| Professional | | $1,173.07 | $1,573.38 | $14,011.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,141.52 / $3,141.52
| Facility | | $3,141.52 | $3,141.52 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $3,141.52 / $3,235.77
| Professional | | $2,293.31 | $3,141.52 | $3,235.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.54 / $2,658.94 / $3,456.62
| Professional | | $1,648.54 | $2,658.94 | $3,456.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,189.29 / $3,556.90 / $3,556.90
| Facility | | $3,189.29 | $3,556.90 | $3,556.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.42 / $2,549.58 / $3,824.37
| Professional | | $2,025.42 | $2,549.58 | $3,824.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.66 / $1,817.08 / $2,606.83
| Professional | | $1,640.66 | $1,817.08 | $2,606.83 |