- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,420.17 / $2,420.17 / $2,420.17
| Facility | | $2,420.17 | $2,420.17 | $2,420.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,008.23 / $2,008.23 / $2,420.17
| Professional | | $2,008.23 | $2,008.23 | $2,420.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,697.90 / $4,676.01 / $5,845.01
| Professional | | $3,697.90 | $4,676.01 | $5,845.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,429.96 / $2,915.28 / $4,726.55
| Facility | | $2,429.96 | $2,915.28 | $4,726.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.07 / $1,544.79 / $5,066.91
| Professional | | $1,313.07 | $1,544.79 | $5,066.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,089.58 / $3,347.05 / $5,642.57
| Facility | | $3,089.58 | $3,347.05 | $5,642.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,089.58 / $3,913.47 / $5,303.78
| Professional | | $3,089.58 | $3,913.47 | $5,303.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,681.75 / $6,203.10 / $7,073.08
| Professional | | $3,681.75 | $6,203.10 | $7,073.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $1,313.07 / $2,574.65
| Professional | | $1,081.34 | $1,313.07 | $2,574.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.65 / $2,574.65 / $2,574.65
| Professional | | $2,574.65 | $2,574.65 | $2,574.65 |