- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,707.11 / $1,963.18
| Facility | | $1,645.41 | $1,707.11 | $1,963.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,707.11 / $1,748.25
| Professional | | $1,645.41 | $1,707.11 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $5,658.44
| Facility | | $1,748.25 | $1,748.25 | $5,658.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.09 / $168.57 / $1,687.76
| Facility | | $162.09 | $168.57 | $1,687.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.90 / $1,687.76 / $1,687.76
| Professional | | $748.90 | $1,687.76 | $1,687.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $3,021.09
| Professional | | $50.00 | $50.00 | $3,021.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $1,765.39
| Professional | | $1,713.97 | $1,713.97 | $1,765.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.03 / $1,789.03 / $1,789.03
| Professional | | $1,789.03 | $1,789.03 | $1,789.03 |