- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.82 / $1,191.82 / $1,191.82
| Facility | | $1,191.82 | $1,191.82 | $1,191.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.82 / $1,466.50 / $13,059.90
| Professional | | $1,191.82 | $1,466.50 | $13,059.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $2,717.61
| Facility | | $2,717.61 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $2,717.61 / $2,844.80
| Professional | | $1,983.86 | $2,717.61 | $2,844.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.17 / $3,601.89 / $4,682.45
| Professional | | $2,233.17 | $3,601.89 | $4,682.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,320.32 / $4,818.29 / $4,818.29
| Facility | | $4,320.32 | $4,818.29 | $4,818.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,743.70 / $3,453.75 / $5,180.63
| Professional | | $2,743.70 | $3,453.75 | $5,180.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.88 / $1,846.11 / $2,648.48
| Professional | | $1,666.88 | $1,846.11 | $2,648.48 |