- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,657.60 / $4,299.07 / $11,637.20
| Facility | | $2,657.60 | $4,299.07 | $11,637.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.12 / $11,637.20 / $11,637.20
| Professional | | $1,954.12 | $11,637.20 | $11,637.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,010.04 / $7,633.53 / $12,092.58
| Facility | | $2,010.04 | $7,633.53 | $12,092.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,913.73 / $2,783.60 / $13,483.06
| Professional | | $1,913.73 | $2,783.60 | $13,483.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,006.90 / $5,118.63 / $8,531.06
| Facility | | $2,006.90 | $5,118.63 | $8,531.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,954.12 / $2,916.60 / $5,202.88
| Facility | | $1,954.12 | $2,916.60 | $5,202.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,224.97 / $14,583.00
| Professional | | $1,224.97 | $1,224.97 | $14,583.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.97 / $1,224.97 / $1,749.96
| Professional | | $1,224.97 | $1,224.97 | $1,749.96 |