- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.23 / $1,357.23 / $1,357.23
| Facility | | $1,357.23 | $1,357.23 | $1,357.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.23 / $1,365.28 / $12,158.50
| Professional | | $1,357.23 | $1,365.28 | $12,158.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,741.63 / $2,823.88
| Professional | | $2,001.39 | $2,741.63 | $2,823.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.40 / $3,157.11 / $4,104.24
| Professional | | $1,957.40 | $3,157.11 | $4,104.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,786.83 / $4,223.30 / $4,223.30
| Facility | | $3,786.83 | $4,223.30 | $4,223.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.91 / $3,027.26 / $4,540.89
| Professional | | $2,404.91 | $3,027.26 | $4,540.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.22 / $2,102.33 / $3,016.06
| Professional | | $1,898.22 | $2,102.33 | $3,016.06 |