- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.09 / $1,308.09 / $1,308.09
| Facility | | $1,308.09 | $1,308.09 | $1,308.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.09 / $1,437.69 / $12,803.30
| Professional | | $1,308.09 | $1,437.69 | $12,803.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $2,941.06
| Facility | | $2,941.06 | $2,941.06 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $5,323.33
| Professional | | $2,146.96 | $2,146.96 | $5,323.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.38 / $3,355.46 / $4,362.09
| Professional | | $2,080.38 | $3,355.46 | $4,362.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,024.73 / $4,488.63 / $4,488.63
| Facility | | $4,024.73 | $4,488.63 | $4,488.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,555.98 / $3,217.45 / $4,826.18
| Professional | | $2,555.98 | $3,217.45 | $4,826.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,829.51 / $2,026.24 / $2,906.89
| Professional | | $1,829.51 | $2,026.24 | $2,906.89 |