- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,567.41 / $2,567.41 / $2,567.41
| Facility | | $2,567.41 | $2,567.41 | $2,567.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.93 / $1,682.10 / $2,567.41
| Professional | | $935.93 | $1,682.10 | $2,567.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,502.08 / $2,633.77 / $2,801.63
| Facility | | $2,502.08 | $2,633.77 | $2,801.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,765.46 / $2,765.46 / $2,765.46
| Professional | | $2,765.46 | $2,765.46 | $2,765.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.81 / $1,815.81 / $1,815.81
| Facility | | $1,815.81 | $1,815.81 | $1,815.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.54 / $1,815.81 / $4,666.88
| Professional | | $1,325.54 | $1,815.81 | $4,666.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.93 / $2,498.71 / $15,138.02
| Facility | | $935.93 | $2,498.71 | $15,138.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.50 / $1,546.78 / $3,961.02
| Professional | | $966.50 | $1,546.78 | $3,961.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.50 / $1,546.78 / $2,122.31
| Professional | | $966.50 | $1,546.78 | $2,122.31 |