- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,821.13 / $1,821.13 / $1,821.13
| Facility | | $1,821.13 | $1,821.13 | $1,821.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.42 / $1,821.13 / $2,887.01
| Professional | | $1,608.42 | $1,821.13 | $2,887.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,642.26 / $4,092.44 / $7,430.21
| Facility | | $3,642.26 | $4,092.44 | $7,430.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.15 / $2,225.15 / $2,433.05
| Professional | | $2,225.15 | $2,225.15 | $2,433.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,141.52 / $3,141.52
| Facility | | $3,141.52 | $3,141.52 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $2,293.31 / $4,753.21
| Professional | | $2,293.31 | $2,293.31 | $4,753.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,173.07 / $1,948.61 / $4,552.83
| Facility | | $1,173.07 | $1,948.61 | $4,552.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.07 / $1,173.07 / $1,173.07
| Professional | | $1,173.07 | $1,173.07 | $1,173.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,658.85 / $4,552.83 / $7,284.52
| Professional | | $2,658.85 | $4,552.83 | $7,284.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.04 / $1,817.08 / $2,800.07
| Professional | | $1,680.04 | $1,817.08 | $2,800.07 |