- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,474.07 / $1,474.07 / $1,474.07
| Facility | | $1,474.07 | $1,474.07 | $1,474.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.07 / $1,977.10 / $17,607.00
| Professional | | $1,474.07 | $1,977.10 | $17,607.00 |
- 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 / $3,638.31
| Professional | | $2,578.61 | $3,532.34 | $3,638.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.84 / $4,430.39 / $5,759.52
| Professional | | $2,746.84 | $4,430.39 | $5,759.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,314.08 / $5,926.59 / $5,926.59
| Facility | | $5,314.08 | $5,926.59 | $5,926.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,374.81 / $4,248.18 / $6,372.27
| Professional | | $3,374.81 | $4,248.18 | $6,372.27 |
- 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
- $2,111.12 / $2,283.32 / $4,551.62
| Professional | | $2,111.12 | $2,283.32 | $4,551.62 |