- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,162.28 / $3,162.28
| Facility | | $1,819.70 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $3,467.37
| Professional | | $1,659.59 | $2,187.76 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $7,943.28
| Facility | | $3,715.35 | $4,168.69 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,238.72 / $2,884.03
| Professional | | $2,187.76 | $2,238.72 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $3,235.94
| Professional | | $2,290.87 | $2,290.87 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,715.35 / $9,120.11
| Professional | | $2,238.72 | $3,715.35 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $3,715.35
| Professional | | $3,630.78 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,398.83 / $2,818.38
| Facility | | $1,659.59 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,819.70 / $2,754.23
| Professional | | $1,659.59 | $1,819.70 | $2,754.23 |