- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,393.29 / $3,393.29 / $3,393.29
| Facility | | $3,393.29 | $3,393.29 | $3,393.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.80 / $2,362.42 / $3,779.87
| Professional | | $1,192.80 | $2,362.42 | $3,779.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,449.56 / $3,631.12 / $3,862.54
| Facility | | $3,449.56 | $3,631.12 | $3,862.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,812.68 / $3,812.68 / $3,812.68
| Professional | | $3,812.68 | $3,812.68 | $3,812.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $2,970.85 / $2,970.85
| Facility | | $2,970.85 | $2,970.85 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,970.85 / $6,109.22
| Professional | | $2,168.71 | $2,970.85 | $6,109.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,192.80 / $3,636.93 / $19,143.40
| Facility | | $1,192.80 | $3,636.93 | $19,143.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.75 / $2,474.56 / $5,765.35
| Professional | | $1,231.75 | $2,474.56 | $5,765.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.91 / $2,251.37 / $3,015.32
| Professional | | $1,500.91 | $2,251.37 | $3,015.32 |