- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,041.74
| Professional | | $1,905.46 | $1,905.46 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $3,715.35
| Facility | | $2,344.23 | $3,467.37 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $125.89 / $2,041.74
| Professional | | $102.33 | $125.89 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $7,244.36 / $10,232.93
| Facility | | $3,548.13 | $7,244.36 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,630.27 / $3,019.95
| Professional | | $2,398.83 | $2,630.27 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,585.78 / $9,332.54
| Facility | | $3,981.07 | $7,585.78 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,570.40
| Professional | | $2,398.83 | $2,398.83 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $3,630.78
| Facility | | $2,041.74 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,754.23
| Professional | | $2,041.74 | $2,041.74 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,949.84 / $2,454.71
| Professional | | $125.89 | $1,949.84 | $2,454.71 |