- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,466.96 / $2,466.96 / $2,466.96
| Facility | | $2,466.96 | $2,466.96 | $2,466.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.50 / $2,466.96 / $2,786.61
| Professional | | $1,466.50 | $2,466.96 | $2,786.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,933.93 / $5,543.76 / $10,065.21
| Facility | | $4,933.93 | $5,543.76 | $10,065.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.71 / $2,260.71 / $2,441.57
| Professional | | $2,260.71 | $2,260.71 | $2,441.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $2,717.61 / $2,717.61
| Facility | | $2,717.61 | $2,717.61 | $2,717.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.86 / $1,983.86 / $4,472.60
| Professional | | $1,983.86 | $1,983.86 | $4,472.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.82 / $2,466.96 / $6,167.41
| Facility | | $1,191.82 | $2,466.96 | $6,167.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.82 / $1,191.82 / $1,191.82
| Professional | | $1,191.82 | $1,191.82 | $1,191.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,601.77 / $6,167.41 / $9,769.18
| Professional | | $3,601.77 | $6,167.41 | $9,769.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.88 / $1,846.11 / $2,844.80
| Professional | | $1,706.88 | $1,846.11 | $2,844.80 |