- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.52 / $1,157.52 / $2,972.00
| Facility | | $1,157.52 | $1,157.52 | $2,972.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.52 / $1,428.25 / $2,972.00
| Professional | | $1,157.52 | $1,428.25 | $2,972.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,572.74 / $3,572.74 / $3,572.74
| Facility | | $3,572.74 | $3,572.74 | $3,572.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.35 / $1,619.41 / $3,572.74
| Professional | | $1,609.35 | $1,619.41 | $3,572.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,630.17
| Facility | | $2,283.76 | $2,283.76 | $2,630.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $2,076.92 / $2,434.60
| Professional | | $1,667.14 | $2,076.92 | $2,434.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,986.76 / $2,858.19 / $4,644.56
| Professional | | $1,986.76 | $2,858.19 | $4,644.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.70 / $1,336.80 / $2,228.00
| Professional | | $1,046.70 | $1,336.80 | $2,228.00 |