- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,575.92 / $2,575.92 / $2,575.92
| Facility | | $2,575.92 | $2,575.92 | $2,575.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,575.92 / $2,575.92 / $3,037.27
| Professional | | $2,575.92 | $2,575.92 | $3,037.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,550.15 / $3,905.15 / $3,944.61
| Professional | | $3,550.15 | $3,905.15 | $3,944.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $4,443.21 / $4,443.21
| Facility | | $2,282.71 | $4,443.21 | $4,443.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,322.16 / $4,710.75 / $6,851.52
| Professional | | $4,322.16 | $4,710.75 | $6,851.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,035.78 / $4,379.06 / $19,065.24
| Facility | | $2,035.78 | $4,379.06 | $19,065.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.86 / $2,430.05 / $3,358.59
| Professional | | $1,537.86 | $2,430.05 | $3,358.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,430.21 / $4,443.21 / $5,598.28
| Facility | | $4,430.21 | $4,443.21 | $5,598.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,694.45 / $5,251.06 / $9,153.73
| Professional | | $3,694.45 | $5,251.06 | $9,153.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.86 / $2,015.15 / $2,808.47
| Professional | | $1,537.86 | $2,015.15 | $2,808.47 |