- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,102.76 / $3,102.76 / $3,102.76
| Facility | | $3,102.76 | $3,102.76 | $3,102.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,579.17 / $3,102.76 / $3,296.69
| Professional | | $2,579.17 | $3,102.76 | $3,296.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,947.04 / $3,204.18 / $8,080.53
| Facility | | $2,947.04 | $3,204.18 | $8,080.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,102.76 / $3,878.45 / $4,615.35
| Facility | | $3,102.76 | $3,878.45 | $4,615.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,520.98 / $2,520.98 / $3,878.45
| Professional | | $2,520.98 | $2,520.98 | $3,878.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,266.30 / $5,934.03 / $7,427.23
| Professional | | $4,266.30 | $5,934.03 | $7,427.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.23 / $2,327.07 / $3,994.80
| Professional | | $1,939.23 | $2,327.07 | $3,994.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,748.50 / $18,422.64 / $18,422.64
| Facility | | $6,748.50 | $18,422.64 | $18,422.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19,314.68 / $19,314.68 / $29,088.38
| Professional | | $19,314.68 | $19,314.68 | $29,088.38 |