- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,298.17 / $2,298.17 / $2,298.17
| Facility | | $2,298.17 | $2,298.17 | $2,298.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.69 / $2,298.17 / $3,441.94
| Professional | | $1,437.69 | $2,298.17 | $3,441.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.35 / $5,164.47 / $9,376.57
| Facility | | $4,596.35 | $5,164.47 | $9,376.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,731.58 / $2,731.58 / $2,950.11
| Professional | | $2,731.58 | $2,731.58 | $2,950.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $2,941.06
| Facility | | $2,941.06 | $2,941.06 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $5,270.63
| Professional | | $2,146.96 | $2,146.96 | $5,270.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.09 / $2,298.17 / $6,107.59
| Facility | | $1,308.09 | $2,298.17 | $6,107.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.09 / $1,308.09 / $1,308.09
| Professional | | $1,308.09 | $1,308.09 | $1,308.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,355.34 / $5,745.45 / $9,192.71
| Professional | | $3,355.34 | $5,745.45 | $9,192.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.42 / $2,026.24 / $3,122.37
| Professional | | $1,873.42 | $2,026.24 | $3,122.37 |