- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,963.73 / $1,963.73 / $1,963.73
| Facility | | $1,963.73 | $1,963.73 | $1,963.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.73 / $2,244.27 / $2,315.86
| Professional | | $1,963.73 | $2,244.27 | $2,315.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,532.34 / $3,532.34 / $3,532.34
| Facility | | $3,532.34 | $3,532.34 | $3,532.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.61 / $3,532.34 / $3,532.34
| Professional | | $2,578.61 | $3,532.34 | $3,532.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,474.07 / $2,748.86 / $24,019.87
| Facility | | $1,474.07 | $2,748.86 | $24,019.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.22 / $3,017.28 / $4,633.20
| Professional | | $1,522.22 | $3,017.28 | $4,633.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,050.06 / $3,050.06 / $3,050.06
| Facility | | $3,050.06 | $3,050.06 | $3,050.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.22 / $2,283.32 / $3,439.51
| Professional | | $1,522.22 | $2,283.32 | $3,439.51 |