- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,457.51 / $2,457.51 / $2,457.51
| Facility | | $2,457.51 | $2,457.51 | $2,457.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,457.51 / $2,833.26 / $4,745.60
| Professional | | $2,457.51 | $2,833.26 | $4,745.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,959.91 / $3,806.64 / $7,952.50
| Professional | | $2,959.91 | $3,806.64 | $7,952.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.47 / $460.23 / $4,194.08
| Facility | | $338.47 | $460.23 | $4,194.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.05 / $451.29 / $4,061.67
| Professional | | $313.05 | $451.29 | $4,061.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $5,376.08
| Facility | | $2,673.00 | $2,673.00 | $5,376.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.05 / $2,673.00 / $4,219.47
| Professional | | $2,272.05 | $2,673.00 | $4,219.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $3,172.80
| Facility | | $2,673.00 | $2,673.00 | $3,172.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.05 / $2,673.00 / $3,214.80
| Professional | | $2,272.05 | $2,673.00 | $3,214.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.71 / $534.86 / $3,342.94
| Professional | | $250.71 | $534.86 | $3,342.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.92 / $2,131.92 / $3,546.56
| Professional | | $1,193.92 | $2,131.92 | $3,546.56 |