- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.68 / $1,444.68 / $1,444.68
| Facility | | $1,444.68 | $1,444.68 | $1,444.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.68 / $1,679.37 / $14,955.60
| Professional | | $1,444.68 | $1,679.37 | $14,955.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $2,802.84
| Facility | | $2,802.84 | $2,802.84 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,802.84 / $2,886.93
| Professional | | $2,382.41 | $2,802.84 | $2,886.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.27 / $1,803.80 / $4,208.45
| Professional | | $860.27 | $1,803.80 | $4,208.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,145.47 / $4,623.30 / $4,623.30
| Facility | | $4,145.47 | $4,623.30 | $4,623.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,632.67 / $3,313.98 / $4,970.97
| Professional | | $2,632.67 | $3,313.98 | $4,970.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.54 / $2,237.80 / $3,210.41
| Professional | | $2,020.54 | $2,237.80 | $3,210.41 |