- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $2,016.42
| Facility | | $2,016.42 | $2,016.42 | $2,016.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $4,688.18
| Professional | | $2,016.42 | $2,016.42 | $4,688.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,825.83 / $2,318.88 / $4,388.49
| Facility | | $1,825.83 | $2,318.88 | $4,388.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.24 / $1,976.55 / $1,976.55
| Professional | | $1,581.24 | $1,976.55 | $1,976.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,664.34 / $6,305.78 / $7,676.90
| Facility | | $3,664.34 | $6,305.78 | $7,676.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.17 / $2,322.89 / $2,491.17
| Professional | | $1,981.17 | $2,322.89 | $2,491.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,160.72 / $5,754.44 / $7,222.08
| Facility | | $3,160.72 | $5,754.44 | $7,222.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.55 / $1,961.55 / $2,667.71
| Professional | | $1,961.55 | $1,961.55 | $2,667.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.55 / $3,340.37 / $4,629.08
| Facility | | $1,976.55 | $3,340.37 | $4,629.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.55 / $1,976.55 / $2,728.03
| Professional | | $1,976.55 | $1,976.55 | $2,728.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.42 / $2,016.42 / $3,655.37
| Professional | | $2,016.42 | $2,016.42 | $3,655.37 |