- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,977.10 / $1,977.10 / $5,076.33
| Facility | | $1,977.10 | $1,977.10 | $5,076.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,977.10 / $2,439.52 / $5,076.33
| Professional | | $1,977.10 | $2,439.52 | $5,076.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,102.42 / $6,102.42 / $6,102.42
| Facility | | $6,102.42 | $6,102.42 | $6,102.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,748.86 / $2,796.11 / $6,102.42
| Professional | | $2,748.86 | $2,796.11 | $6,102.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,532.34 / $3,532.34 / $4,492.46
| Facility | | $3,532.34 | $3,532.34 | $4,492.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.61 / $3,456.43 / $3,874.98
| Professional | | $2,578.61 | $3,456.43 | $3,874.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,393.49 / $4,881.93 / $7,933.15
| Professional | | $3,393.49 | $4,881.93 | $7,933.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,050.06 / $3,050.06 / $3,050.06
| Facility | | $3,050.06 | $3,050.06 | $3,050.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,149.29 / $3,439.51 / $5,492.18
| Professional | | $2,149.29 | $3,439.51 | $5,492.18 |