- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.49 / $1,095.49 / $1,095.49
| Facility | | $1,095.49 | $1,095.49 | $1,095.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.49 / $1,204.02 / $10,722.30
| Professional | | $1,095.49 | $1,204.02 | $10,722.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $2,463.07
| Facility | | $2,463.07 | $2,463.07 | $2,463.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $2,463.07 / $2,625.75
| Professional | | $1,798.04 | $2,463.07 | $2,625.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.25 / $2,810.09 / $3,653.11
| Professional | | $1,742.25 | $2,810.09 | $3,653.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,370.59 / $3,759.09 / $3,759.09
| Facility | | $3,370.59 | $3,759.09 | $3,759.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,140.55 / $2,694.52 / $4,041.78
| Professional | | $2,140.55 | $2,694.52 | $4,041.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,532.16 / $1,696.91 / $2,434.42
| Professional | | $1,532.16 | $1,696.91 | $2,434.42 |