- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.54 / $2,527.54 / $5,244.64
| Facility | | $2,527.54 | $2,527.54 | $5,244.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.01 / $2,527.54 / $2,527.54
| Professional | | $2,101.01 | $2,527.54 | $2,527.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.67 / $4,398.09 / $8,294.01
| Facility | | $2,400.67 | $4,398.09 | $8,294.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.54 / $3,159.42 / $4,739.13
| Facility | | $2,527.54 | $3,159.42 | $4,739.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.62 / $2,053.62 / $3,159.42
| Professional | | $2,053.62 | $2,053.62 | $3,159.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,159.42 / $4,833.91 / $6,050.29
| Professional | | $3,159.42 | $4,833.91 | $6,050.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.71 / $1,895.65 / $3,254.20
| Professional | | $1,579.71 | $1,895.65 | $3,254.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,497.39 / $15,007.25 / $15,007.25
| Facility | | $5,497.39 | $15,007.25 | $15,007.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,733.91 / $15,733.91 / $23,695.65
| Professional | | $15,733.91 | $15,733.91 | $23,695.65 |