- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,712.55 / $1,712.55 / $1,712.55
| Facility | | $1,712.55 | $1,712.55 | $1,712.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,617.25 / $1,712.55 / $2,849.28
| Professional | | $1,617.25 | $1,712.55 | $2,849.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,828.18 / $3,828.18 / $4,606.83
| Professional | | $3,828.18 | $3,828.18 | $4,606.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.52 / $2,463.07 / $2,719.43
| Facility | | $818.52 | $2,463.07 | $2,719.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $2,302.09 / $2,463.07
| Professional | | $1,798.04 | $2,302.09 | $2,463.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,703.52 / $2,743.00 / $6,012.14
| Facility | | $1,703.52 | $2,743.00 | $6,012.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,142.00 / $2,142.00 / $2,142.00
| Professional | | $2,142.00 | $2,142.00 | $2,142.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.82 / $2,586.82 / $2,586.82
| Professional | | $2,586.82 | $2,586.82 | $2,586.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.96 / $1,892.80 / $2,556.73
| Professional | | $1,285.96 | $1,892.80 | $2,556.73 |