- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,422.86 / $2,422.86 / $2,422.86
| Facility | | $2,422.86 | $2,422.86 | $2,422.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.02 / $1,686.80 / $2,698.88
| Professional | | $1,017.02 | $1,686.80 | $2,698.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,167.75 / $3,456.18 / $3,665.94
| Facility | | $3,167.75 | $3,456.18 | $3,665.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,430.53 / $3,430.53 / $3,430.53
| Professional | | $3,430.53 | $3,430.53 | $3,430.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,425.11
| Facility | | $2,425.11 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,425.11 / $5,432.81
| Professional | | $1,770.33 | $2,425.11 | $5,432.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.02 / $2,596.80 / $16,380.05
| Facility | | $1,017.02 | $2,596.80 | $16,380.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.24 / $1,844.92 / $4,116.47
| Professional | | $1,050.24 | $1,844.92 | $4,116.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.67 / $1,607.50 / $2,427.57
| Professional | | $1,071.67 | $1,607.50 | $2,427.57 |