- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,499.16 / $2,499.16 / $2,499.16
| Facility | | $2,499.16 | $2,499.16 | $2,499.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.91 / $1,739.92 / $2,783.87
| Professional | | $1,036.91 | $1,739.92 | $2,783.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,896.44 / $3,160.16 / $3,351.96
| Facility | | $2,896.44 | $3,160.16 | $3,351.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,136.71 / $3,136.71 / $3,136.71
| Professional | | $3,136.71 | $3,136.71 | $3,136.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,861.13 / $2,861.13 / $2,861.13
| Facility | | $2,861.13 | $2,861.13 | $2,861.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.96 / $2,861.13 / $5,227.03
| Professional | | $2,431.96 | $2,861.13 | $5,227.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.91 / $2,678.57 / $16,835.74
| Facility | | $1,036.91 | $2,678.57 | $16,835.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.78 / $1,903.02 / $4,246.12
| Professional | | $1,070.78 | $1,903.02 | $4,246.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.42 / $1,658.12 / $2,475.06
| Professional | | $1,105.42 | $1,658.12 | $2,475.06 |