- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,914.72 / $3,914.72 / $3,914.72
| Facility | | $3,914.72 | $3,914.72 | $3,914.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,999.01 / $2,873.57 / $3,914.72
| Professional | | $1,999.01 | $2,873.57 | $3,914.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,793.86 / $5,793.86 / $5,793.86
| Professional | | $5,793.86 | $5,793.86 | $5,793.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,006.51
| Facility | | $2,290.69 | $2,290.69 | $3,006.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.08 / $2,290.69 / $4,992.18
| Professional | | $268.08 | $2,290.69 | $4,992.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.32 / $2,873.57 / $4,879.47
| Facility | | $467.32 | $2,873.57 | $4,879.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.55 / $1,741.56 / $3,158.80
| Professional | | $923.55 | $1,741.56 | $3,158.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.66 / $451.22 / $2,308.87
| Facility | | $216.66 | $451.22 | $2,308.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.24 / $1,749.60 / $3,095.19
| Professional | | $964.24 | $1,749.60 | $3,095.19 |