- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,467.37 / $3,467.37
| Professional | | $2,238.72 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,819.70 / $3,548.13
| Facility | | $1,412.54 | $1,819.70 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,548.13 / $3,548.13
| Professional | | $3,388.44 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,265.80 / $5,248.07
| Professional | | $3,981.07 | $4,265.80 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,467.37 / $16,982.44
| Facility | | $630.96 | $3,467.37 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,754.23 / $6,165.95
| Professional | | $1,230.27 | $2,754.23 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,677.35 / $9,120.11
| Professional | | $3,981.07 | $4,677.35 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $588.84 / $3,715.35
| Facility | | $295.12 | $588.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,019.95 / $7,079.46
| Professional | | $1,318.26 | $3,019.95 | $7,079.46 |