- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.33 / $2,162.33 / $2,162.33
| Facility | | $2,162.33 | $2,162.33 | $2,162.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.28 / $2,162.33 / $4,231.14
| Professional | | $1,365.28 | $2,162.33 | $4,231.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,324.66 / $4,859.18 / $8,822.31
| Facility | | $4,324.66 | $4,859.18 | $8,822.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.42 / $2,578.42 / $2,784.69
| Professional | | $2,578.42 | $2,578.42 | $2,784.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $2,741.63
| Facility | | $2,741.63 | $2,741.63 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $4,509.14
| Professional | | $2,001.39 | $2,001.39 | $4,509.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.23 / $2,162.33 / $5,688.93
| Facility | | $1,357.23 | $2,162.33 | $5,688.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.23 / $1,357.23 / $1,357.23
| Professional | | $1,357.23 | $1,357.23 | $1,357.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,157.00 / $5,405.83 / $8,649.32
| Professional | | $3,157.00 | $5,405.83 | $8,649.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.77 / $2,102.33 / $3,239.62
| Professional | | $1,943.77 | $2,102.33 | $3,239.62 |