- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,441.63 / $2,441.63 / $2,441.63
| Facility | | $2,441.63 | $2,441.63 | $2,441.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.42 / $2,441.63 / $3,656.81
| Professional | | $1,527.42 | $2,441.63 | $3,656.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,883.25 / $5,486.82 / $9,961.83
| Facility | | $4,883.25 | $5,486.82 | $9,961.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,902.12 / $2,902.12 / $3,134.29
| Professional | | $2,902.12 | $2,902.12 | $3,134.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $2,886.72
| Facility | | $2,886.72 | $2,886.72 | $2,886.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,107.31 / $5,143.14
| Professional | | $2,107.31 | $2,107.31 | $5,143.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,389.75 / $2,441.63 / $6,104.06
| Facility | | $1,389.75 | $2,441.63 | $6,104.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.75 / $1,389.75 / $1,389.75
| Professional | | $1,389.75 | $1,389.75 | $1,389.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,564.77 / $6,104.06 / $9,668.84
| Professional | | $3,564.77 | $6,104.06 | $9,668.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.36 / $2,152.71 / $3,317.27
| Professional | | $1,990.36 | $2,152.71 | $3,317.27 |