- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,389.03 / $2,389.03 / $2,389.03
| Facility | | $2,389.03 | $2,389.03 | $2,389.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.77 / $2,389.03 / $3,595.65
| Professional | | $1,862.77 | $2,389.03 | $3,595.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,778.05 / $5,368.62 / $9,747.21
| Facility | | $4,778.05 | $5,368.62 | $9,747.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,731.85 / $2,731.85 / $2,950.40
| Professional | | $2,731.85 | $2,731.85 | $2,950.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $3,813.78
| Facility | | $3,813.78 | $3,813.78 | $3,813.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $2,784.06 / $5,387.81
| Professional | | $2,784.06 | $2,784.06 | $5,387.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.20 / $2,493.05 / $5,972.56
| Facility | | $1,440.20 | $2,493.05 | $5,972.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.20 / $1,440.20 / $1,440.20
| Professional | | $1,440.20 | $1,440.20 | $1,440.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,487.98 / $5,972.56 / $9,556.10
| Professional | | $3,487.98 | $5,972.56 | $9,556.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.61 / $2,230.86 / $3,437.68
| Professional | | $2,062.61 | $2,230.86 | $3,437.68 |