- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,266.64 / $2,266.64 / $2,266.64
| Facility | | $2,266.64 | $2,266.64 | $2,266.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.64 / $2,280.09 / $20,305.30
| Professional | | $2,266.64 | $2,280.09 | $20,305.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,697.47 / $4,697.47 / $4,697.47
| Facility | | $4,697.47 | $4,697.47 | $4,697.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,429.16 / $3,429.16 / $8,502.56
| Professional | | $3,429.16 | $3,429.16 | $8,502.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,342.18 / $5,390.62 / $7,007.80
| Professional | | $3,342.18 | $5,390.62 | $7,007.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,465.82 / $7,211.09 / $7,211.09
| Facility | | $6,465.82 | $7,211.09 | $7,211.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,106.22 / $5,168.91 / $7,753.37
| Professional | | $4,106.22 | $5,168.91 | $7,753.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,170.12 / $3,511.00 / $5,036.97
| Professional | | $3,170.12 | $3,511.00 | $5,036.97 |