- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,026.28 / $2,026.28 / $2,026.28
| Facility | | $2,026.28 | $2,026.28 | $2,026.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.31 / $2,026.28 / $2,770.34
| Professional | | $1,437.31 | $2,026.28 | $2,770.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,122.79
| Facility | | $1,772.06 | $1,772.06 | $2,122.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.25 / $1,772.06 / $1,925.80
| Professional | | $1,506.25 | $1,772.06 | $1,925.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,603.89 / $2,000.81 / $2,770.34
| Facility | | $1,603.89 | $2,000.81 | $2,770.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,115.96 / $2,233.52 / $2,406.83
| Professional | | $2,115.96 | $2,233.52 | $2,406.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.46 / $1,984.63 / $2,038.02
| Professional | | $198.46 | $1,984.63 | $2,038.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,336.73 / $2,336.73 / $4,018.30
| Facility | | $2,336.73 | $2,336.73 | $4,018.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.93 / $1,095.27 / $2,022.42
| Facility | | $129.93 | $1,095.27 | $2,022.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.65 / $1,216.33 / $2,201.11
| Professional | | $1,113.65 | $1,216.33 | $2,201.11 |