- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,221.05 / $2,221.05 / $3,511.00
| Facility | | $2,221.05 | $2,221.05 | $3,511.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,221.05 / $2,221.05 / $4,818.42
| Professional | | $2,221.05 | $2,221.05 | $4,818.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,015.31 / $2,456.92 / $3,045.49
| Professional | | $2,015.31 | $2,456.92 | $3,045.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,695.49 / $3,753.57 / $8,143.13
| Facility | | $1,695.49 | $3,753.57 | $8,143.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.65 / $2,605.21 / $27,827.90
| Professional | | $1,551.65 | $2,605.21 | $27,827.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,045.49 / $3,736.60 / $5,795.32
| Facility | | $3,045.49 | $3,736.60 | $5,795.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,518.35 / $3,045.49 / $3,958.97
| Professional | | $2,518.35 | $3,045.49 | $3,958.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $6,571.00 / $6,571.00
| Facility | | $6,571.00 | $6,571.00 | $6,571.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.34 / $3,697.12 / $10,277.84
| Professional | | $1,422.34 | $3,697.12 | $10,277.84 |