- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.02 / $1,017.02 / $1,017.02
| Facility | | $1,017.02 | $1,017.02 | $1,017.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.02 / $1,104.75 / $9,838.32
| Professional | | $1,017.02 | $1,104.75 | $9,838.32 |
- 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 / $2,497.86
| Professional | | $1,770.33 | $2,425.11 | $2,497.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.03 / $2,483.92 / $3,229.09
| Professional | | $1,540.03 | $2,483.92 | $3,229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,979.36 / $3,322.76 / $3,322.76
| Facility | | $2,979.36 | $3,322.76 | $3,322.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.09 / $2,381.76 / $3,572.64
| Professional | | $1,892.09 | $2,381.76 | $3,572.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.41 / $1,575.35 / $2,260.05
| Professional | | $1,422.41 | $1,575.35 | $2,260.05 |