- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,926.83 / $1,926.83 / $1,926.83
| Facility | | $1,926.83 | $1,926.83 | $1,926.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.08 / $1,926.83 / $2,711.60
| Professional | | $1,752.08 | $1,926.83 | $2,711.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.62 / $1,893.62 / $1,893.62
| Professional | | $1,893.62 | $1,893.62 | $1,893.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,022.10 / $3,022.10 / $3,022.10
| Professional | | $3,022.10 | $3,022.10 | $3,022.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,032.02 / $2,387.48 / $2,387.48
| Facility | | $2,032.02 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.33 / $2,387.48 / $2,387.48
| Professional | | $284.33 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.33 / $1,752.08 / $1,982.03
| Facility | | $320.33 | $1,752.08 | $1,982.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,705.40 / $2,705.40 / $2,705.40
| Professional | | $2,705.40 | $2,705.40 | $2,705.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.53 / $364.30 / $3,220.75
| Facility | | $205.53 | $364.30 | $3,220.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.53 / $364.30 / $3,220.75
| Professional | | $205.53 | $364.30 | $3,220.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.57 / $1,353.88 / $2,027.73
| Professional | | $1,111.57 | $1,353.88 | $2,027.73 |