- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,808.02 / $2,808.02 / $2,808.02
| Facility | | $2,808.02 | $2,808.02 | $2,808.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.07 / $1,954.95 / $3,127.92
| Professional | | $1,165.07 | $1,954.95 | $3,127.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,254.41 / $3,550.72 / $3,766.23
| Facility | | $3,254.41 | $3,550.72 | $3,766.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,524.38 / $3,524.38 / $3,524.38
| Professional | | $3,524.38 | $3,524.38 | $3,524.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.74 / $3,214.74 / $3,214.74
| Facility | | $3,214.74 | $3,214.74 | $3,214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.53 / $3,214.74 / $5,872.97
| Professional | | $2,732.53 | $3,214.74 | $5,872.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.07 / $3,009.62 / $18,916.50
| Facility | | $1,165.07 | $3,009.62 | $18,916.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.11 / $2,138.21 / $4,770.91
| Professional | | $1,203.11 | $2,138.21 | $4,770.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.03 / $1,863.05 / $2,780.96
| Professional | | $1,242.03 | $1,863.05 | $2,780.96 |