- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.73 / $2,050.73 / $2,050.73
| Facility | | $2,050.73 | $2,050.73 | $2,050.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,955.13 / $2,050.73 / $3,028.48
| Professional | | $1,955.13 | $2,050.73 | $3,028.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.48 / $2,077.48 / $2,077.48
| Professional | | $2,077.48 | $2,077.48 | $2,077.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,411.87 / $3,411.87 / $3,715.91
| Professional | | $3,411.87 | $3,411.87 | $3,715.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.08 / $2,592.00 / $2,683.93
| Professional | | $296.08 | $2,592.00 | $2,683.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.93 / $2,249.19 / $2,541.60
| Facility | | $340.93 | $2,249.19 | $2,541.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,473.10 / $3,473.10 / $3,473.10
| Professional | | $3,473.10 | $3,473.10 | $3,473.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $232.42 / $458.82 / $3,969.24
| Facility | | $232.42 | $458.82 | $3,969.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.42 / $458.82 / $3,969.24
| Professional | | $232.42 | $458.82 | $3,969.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.69 / $1,592.00 / $2,526.08
| Professional | | $1,263.69 | $1,592.00 | $2,526.08 |