- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.14 / $1,077.14 / $1,077.14
| Facility | | $1,077.14 | $1,077.14 | $1,077.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.14 / $1,183.83 / $10,542.60
| Professional | | $1,077.14 | $1,183.83 | $10,542.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,264.80 / $2,264.80
| Facility | | $2,264.80 | $2,264.80 | $2,264.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $2,264.80 / $2,414.39
| Professional | | $1,653.30 | $2,264.80 | $2,414.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.06 / $2,763.01 / $3,591.91
| Professional | | $1,713.06 | $2,763.01 | $3,591.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,314.11 / $3,696.10 / $3,696.10
| Facility | | $3,314.11 | $3,696.10 | $3,696.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.69 / $2,649.37 / $3,974.05
| Professional | | $2,104.69 | $2,649.37 | $3,974.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.48 / $1,668.47 / $2,387.65
| Professional | | $1,506.48 | $1,668.47 | $2,387.65 |