- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.25 / $1,951.25 / $1,951.25
| Facility | | $1,951.25 | $1,951.25 | $1,951.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.06 / $1,805.95 / $1,951.25
| Professional | | $1,453.06 | $1,805.95 | $1,951.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,013.53 / $2,075.80 / $2,075.80
| Facility | | $2,013.53 | $2,075.80 | $2,075.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.64 / $2,075.80 / $2,075.80
| Professional | | $1,660.64 | $2,075.80 | $2,075.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,339.11 / $7,789.05 / $18,214.32
| Facility | | $5,339.11 | $7,789.05 | $18,214.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,408.92 / $3,029.05 / $3,985.01
| Professional | | $2,408.92 | $3,029.05 | $3,985.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,204.02 / $6,922.19 / $14,341.99
| Facility | | $4,204.02 | $6,922.19 | $14,341.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,385.08 / $3,769.92
| Professional | | $2,385.08 | $2,385.08 | $3,769.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,868.22 / $2,594.59 / $9,860.04
| Facility | | $1,868.22 | $2,594.59 | $9,860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,322.28 / $4,404.43
| Professional | | $871.84 | $1,322.28 | $4,404.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.84 / $1,245.48 / $4,420.77
| Professional | | $871.84 | $1,245.48 | $4,420.77 |