- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,701.26 / $1,701.26 / $1,701.26
| Facility | | $1,701.26 | $1,701.26 | $1,701.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.10 / $1,701.26 / $2,673.13
| Professional | | $1,386.10 | $1,701.26 | $2,673.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,402.51 / $3,823.06 / $6,941.12
| Facility | | $3,402.51 | $3,823.06 | $6,941.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.14 / $1,929.14 / $2,083.46
| Professional | | $1,929.14 | $1,929.14 | $2,083.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,425.11
| Facility | | $2,425.11 | $2,425.11 | $2,425.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $1,770.33 / $3,447.82
| Professional | | $1,770.33 | $1,770.33 | $3,447.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.02 / $1,760.50 / $4,253.14
| Facility | | $1,017.02 | $1,760.50 | $4,253.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.02 / $1,017.02 / $1,017.02
| Professional | | $1,017.02 | $1,017.02 | $1,017.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,483.83 / $4,253.14 / $6,805.02
| Professional | | $2,483.83 | $4,253.14 | $6,805.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,456.54 / $1,575.35 / $2,427.57
| Professional | | $1,456.54 | $1,575.35 | $2,427.57 |