- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.04 / $1,278.04 / $1,278.04
| Facility | | $1,278.04 | $1,278.04 | $1,278.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.75 / $1,278.04 / $1,979.77
| Professional | | $983.75 | $1,278.04 | $1,979.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,556.07 / $2,872.00 / $5,214.38
| Facility | | $2,556.07 | $2,872.00 | $5,214.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.04 / $1,381.04 / $1,491.52
| Professional | | $1,381.04 | $1,381.04 | $1,491.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $1,747.16
| Facility | | $1,747.16 | $1,747.16 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,275.43 / $2,467.35
| Professional | | $1,275.43 | $1,275.43 | $2,467.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.07 / $1,278.04 / $3,195.09
| Facility | | $728.07 | $1,278.04 | $3,195.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.07 / $728.07 / $728.07
| Professional | | $728.07 | $728.07 | $728.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.93 / $3,195.09 / $5,061.02
| Professional | | $1,865.93 | $3,195.09 | $5,061.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.72 / $1,127.77 / $1,737.86
| Professional | | $1,042.72 | $1,127.77 | $1,737.86 |