- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,998.63 / $1,998.63 / $1,998.63
| Facility | | $1,998.63 | $1,998.63 | $1,998.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.34 / $1,998.63 / $2,551.44
| Professional | | $1,488.34 | $1,998.63 | $2,551.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,019.89 / $2,126.19 / $2,126.19
| Facility | | $2,019.89 | $2,126.19 | $2,126.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.96 / $2,126.19 / $2,126.19
| Professional | | $1,700.96 | $2,126.19 | $2,126.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,969.09 / $7,755.47 / $18,656.82
| Facility | | $4,969.09 | $7,755.47 | $18,656.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.73 / $3,103.00 / $4,305.13
| Professional | | $2,467.73 | $3,103.00 | $4,305.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,306.16 / $7,090.36 / $14,690.41
| Facility | | $4,306.16 | $7,090.36 | $14,690.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,443.31 / $2,443.31 / $3,861.96
| Professional | | $2,443.31 | $2,443.31 | $3,861.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.19 / $3,827.16 / $5,847.05
| Facility | | $2,126.19 | $3,827.16 | $5,847.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.35 / $1,700.96 / $5,606.36
| Professional | | $1,084.35 | $1,700.96 | $5,606.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.09 / $1,354.39 / $4,609.60
| Professional | | $1,063.09 | $1,354.39 | $4,609.60 |