- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.18 / $1,905.18 / $1,905.18
| Facility | | $1,905.18 | $1,905.18 | $1,905.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.18 / $1,905.18 / $2,246.40
| Professional | | $1,905.18 | $1,905.18 | $2,246.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,625.73 / $2,888.30 / $2,917.48
| Professional | | $2,625.73 | $2,888.30 | $2,917.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.29 / $3,286.25 / $3,286.25
| Facility | | $1,808.29 | $3,286.25 | $3,286.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,196.72 / $3,759.00 / $5,067.46
| Professional | | $3,196.72 | $3,759.00 | $5,067.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,624.41 / $3,270.08 / $15,133.20
| Facility | | $1,624.41 | $3,270.08 | $15,133.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.42 / $1,907.82 / $2,484.05
| Professional | | $1,137.42 | $1,907.82 | $2,484.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,276.64 / $3,286.25 / $6,279.94
| Facility | | $3,276.64 | $3,286.25 | $6,279.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.46 / $3,938.60 / $7,468.75
| Professional | | $2,732.46 | $3,938.60 | $7,468.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.42 / $1,490.43 / $2,224.76
| Professional | | $1,137.42 | $1,490.43 | $2,224.76 |