- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.88 / $1,304.88 / $1,304.88
| Facility | | $1,304.88 | $1,304.88 | $1,304.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.88 / $1,516.85 / $13,508.30
| Professional | | $1,304.88 | $1,516.85 | $13,508.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $3,600.52 / $3,600.52
| Facility | | $3,600.52 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,600.52 / $3,708.54
| Professional | | $3,060.44 | $3,600.52 | $3,708.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.00 / $1,629.21 / $3,801.21
| Professional | | $777.00 | $1,629.21 | $3,801.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,744.33 / $4,175.91 / $4,175.91
| Facility | | $3,744.33 | $4,175.91 | $4,175.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,377.91 / $2,993.29 / $4,489.93
| Professional | | $2,377.91 | $2,993.29 | $4,489.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.01 / $2,021.25 / $2,892.48
| Professional | | $1,825.01 | $2,021.25 | $2,892.48 |