- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,138.07 / $2,138.07 / $2,138.07
| Facility | | $2,138.07 | $2,138.07 | $2,138.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.77 / $2,138.07 / $3,304.19
| Professional | | $1,853.77 | $2,138.07 | $3,304.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,276.13 / $4,804.66 / $8,723.31
| Facility | | $4,276.13 | $4,804.66 | $8,723.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,478.96 / $2,478.96 / $2,677.29
| Professional | | $2,478.96 | $2,478.96 | $2,677.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.52 / $3,600.52 / $3,600.52
| Facility | | $3,600.52 | $3,600.52 | $3,600.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.44 / $3,060.44 / $4,475.45
| Professional | | $3,060.44 | $3,060.44 | $4,475.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.88 / $2,258.80 / $5,345.16
| Facility | | $1,304.88 | $2,258.80 | $5,345.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.88 / $1,304.88 / $1,304.88
| Professional | | $1,304.88 | $1,304.88 | $1,304.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,121.57 / $5,345.16 / $8,552.26
| Professional | | $3,121.57 | $5,345.16 | $8,552.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.81 / $2,021.25 / $3,114.68
| Professional | | $1,868.81 | $2,021.25 | $3,114.68 |