- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,360.56 / $2,360.56 / $2,360.56
| Facility | | $2,360.56 | $2,360.56 | $2,360.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.26 / $2,360.56 / $2,783.52
| Professional | | $2,034.26 | $2,360.56 | $2,783.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.10 / $1,823.10 / $2,867.04
| Facility | | $1,823.10 | $1,823.10 | $2,867.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,267.38 / $3,267.38 / $4,084.22
| Professional | | $3,267.38 | $3,267.38 | $4,084.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,273.62 / $3,003.09 / $12,483.67
| Facility | | $2,273.62 | $3,003.09 | $12,483.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.53 / $1,845.77 / $2,979.43
| Professional | | $1,135.53 | $1,845.77 | $2,979.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,383.89 / $2,867.04 / $4,476.64
| Facility | | $2,383.89 | $2,867.04 | $4,476.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.66 / $2,907.39 / $5,478.84
| Professional | | $2,429.66 | $2,907.39 | $5,478.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,377.55 / $2,783.52 / $3,308.65
| Professional | | $2,377.55 | $2,783.52 | $3,308.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.24 / $1,551.72 / $2,369.98
| Professional | | $911.24 | $1,551.72 | $2,369.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.27 / $2,554.27 / $2,554.27
| Professional | | $2,554.27 | $2,554.27 | $2,554.27 |