- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,574.02 / $2,574.02 / $2,574.02
| Facility | | $2,574.02 | $2,574.02 | $2,574.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.24 / $2,574.02 / $3,855.06
| Professional | | $1,610.24 | $2,574.02 | $3,855.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,148.04 / $5,784.34 / $10,502.00
| Facility | | $5,148.04 | $5,784.34 | $10,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,779.11 / $2,779.11 / $3,001.44
| Professional | | $2,779.11 | $2,779.11 | $3,001.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $2,404.69 / $5,422.09
| Professional | | $2,404.69 | $2,404.69 | $5,422.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,465.11 / $2,574.02 / $6,435.05
| Facility | | $1,465.11 | $2,574.02 | $6,435.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.11 / $1,465.11 / $1,465.11
| Professional | | $1,465.11 | $1,465.11 | $1,465.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,758.07 / $6,435.05 / $10,193.12
| Professional | | $3,758.07 | $6,435.05 | $10,193.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.29 / $2,269.44 / $3,497.15
| Professional | | $2,098.29 | $2,269.44 | $3,497.15 |