- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,938.28 / $2,938.28 / $2,938.28
| Facility | | $2,938.28 | $2,938.28 | $2,938.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.84 / $2,045.64 / $3,273.02
| Professional | | $1,129.84 | $2,045.64 | $3,273.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,883.55 / $3,146.11 / $3,337.05
| Facility | | $2,883.55 | $3,146.11 | $3,337.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,122.76 / $3,122.76 / $3,122.76
| Professional | | $3,122.76 | $3,122.76 | $3,122.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.30 / $2,540.30 / $2,540.30
| Facility | | $2,540.30 | $2,540.30 | $2,540.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.42 / $2,540.30 / $5,690.63
| Professional | | $1,854.42 | $2,540.30 | $5,690.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,129.84 / $3,149.23 / $18,286.54
| Facility | | $1,129.84 | $3,149.23 | $18,286.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.75 / $2,237.42 / $4,992.24
| Professional | | $1,166.75 | $2,237.42 | $4,992.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.65 / $1,949.47 / $2,696.88
| Professional | | $1,299.65 | $1,949.47 | $2,696.88 |