- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,965.73 / $2,965.73 / $2,965.73
| Facility | | $2,965.73 | $2,965.73 | $2,965.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,745.51 / $2,965.73 / $4,273.60
| Professional | | $2,745.51 | $2,965.73 | $4,273.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,950.27 / $2,950.27 / $2,950.27
| Professional | | $2,950.27 | $2,950.27 | $2,950.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,265.70 / $5,265.70 / $5,392.97
| Professional | | $5,265.70 | $5,265.70 | $5,392.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,644.69 / $3,626.76 / $3,626.76
| Facility | | $2,644.69 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.27 / $3,626.76 / $3,626.76
| Professional | | $432.27 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,936.64 / $3,024.74 / $4,274.06
| Facility | | $2,936.64 | $3,024.74 | $4,274.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,534.50 / $4,534.50 / $4,534.50
| Professional | | $4,534.50 | $4,534.50 | $4,534.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.89 / $610.58 / $5,182.32
| Facility | | $323.89 | $610.58 | $5,182.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.89 / $610.58 / $5,182.32
| Professional | | $323.89 | $610.58 | $5,182.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.23 / $2,100.84 / $3,398.47
| Professional | | $1,761.23 | $2,100.84 | $3,398.47 |