- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,758.78 / $2,758.78 / $2,758.78
| Facility | | $2,758.78 | $2,758.78 | $2,758.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.36 / $2,724.16 / $2,758.78
| Professional | | $2,467.36 | $2,724.16 | $2,758.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $3,477.42
| Facility | | $1,743.07 | $1,743.07 | $3,477.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,818.25 / $3,818.25 / $4,772.81
| Professional | | $3,818.25 | $3,818.25 | $4,772.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,357.17 / $3,591.29 / $14,630.94
| Facility | | $2,357.17 | $3,591.29 | $14,630.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.32 / $1,855.57 / $3,613.75
| Professional | | $1,111.32 | $1,855.57 | $3,613.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,891.42 / $3,477.42 / $5,353.23
| Facility | | $2,891.42 | $3,477.42 | $5,353.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,848.03 / $3,526.36 / $6,645.28
| Professional | | $2,848.03 | $3,526.36 | $6,645.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.85 / $2,724.16 / $3,238.11
| Professional | | $2,326.85 | $2,724.16 | $3,238.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.66 / $1,855.57 / $2,472.05
| Professional | | $1,089.66 | $1,855.57 | $2,472.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,098.06 / $3,098.06 / $3,098.06
| Professional | | $3,098.06 | $3,098.06 | $3,098.06 |