- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,832.81 / $2,832.81 / $2,832.81
| Facility | | $2,832.81 | $2,832.81 | $2,832.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,832.81 / $2,832.81 / $3,340.18
| Professional | | $2,832.81 | $2,832.81 | $3,340.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,904.21 / $4,294.63 / $4,338.01
| Professional | | $3,904.21 | $4,294.63 | $4,338.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $4,886.33 / $4,886.33
| Facility | | $3,141.52 | $4,886.33 | $4,886.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,141.52 / $4,886.33 / $7,534.82
| Professional | | $3,141.52 | $4,886.33 | $7,534.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,433.05 / $4,844.28 / $18,963.50
| Facility | | $2,433.05 | $4,844.28 | $18,963.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.23 / $2,422.78 / $3,693.54
| Professional | | $1,691.23 | $2,422.78 | $3,693.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,872.04 / $4,886.33 / $6,156.61
| Facility | | $4,872.04 | $4,886.33 | $6,156.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,001.94 / $5,707.91 / $10,066.62
| Professional | | $4,001.94 | $5,707.91 | $10,066.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.31 / $2,401.17 / $2,800.07
| Professional | | $1,642.31 | $2,401.17 | $2,800.07 |