- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.62 / $2,570.62 / $2,570.62
| Facility | | $2,570.62 | $2,570.62 | $2,570.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,909.75 / $2,570.62 / $3,937.75
| Professional | | $1,909.75 | $2,570.62 | $3,937.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,141.22 / $5,776.69 / $10,488.11
| Facility | | $5,141.22 | $5,776.69 | $10,488.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,800.76 / $2,800.76 / $3,024.82
| Professional | | $2,800.76 | $2,800.76 | $3,024.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,670.30 / $3,670.30 / $3,670.30
| Facility | | $3,670.30 | $3,670.30 | $3,670.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.32 / $2,679.32 / $5,594.32
| Professional | | $2,679.32 | $2,679.32 | $5,594.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.53 / $2,570.62 / $6,426.54
| Facility | | $1,476.53 | $2,570.62 | $6,426.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.53 / $1,476.53 / $1,476.53
| Professional | | $1,476.53 | $1,476.53 | $1,476.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,753.10 / $6,426.54 / $10,179.64
| Professional | | $3,753.10 | $6,426.54 | $10,179.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,114.63 / $2,287.12 / $3,524.39
| Professional | | $2,114.63 | $2,287.12 | $3,524.39 |