- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,467.37 / $3,467.37
| Facility | | $1,949.84 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $3,981.07
| Professional | | $1,949.84 | $2,344.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,570.88 / $8,709.64
| Facility | | $3,981.07 | $4,570.88 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $3,162.28
| Professional | | $2,344.23 | $2,951.21 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,884.03
| Professional | | $1,819.70 | $1,819.70 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,981.07 / $9,549.93
| Professional | | $2,398.83 | $3,981.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.16 / $2,630.27 / $3,090.30
| Facility | | $3.16 | $2,630.27 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,949.84 / $3,019.95
| Professional | | $1,778.28 | $1,949.84 | $3,019.95 |