- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,301.65 / $2,301.65 / $2,301.65
| Facility | | $2,301.65 | $2,301.65 | $2,301.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.99 / $2,277.16 / $2,301.65
| Professional | | $1,713.99 | $2,277.16 | $2,301.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.13 / $2,448.56 / $2,448.56
| Facility | | $2,326.13 | $2,448.56 | $2,448.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.85 / $2,448.56 / $2,448.56
| Professional | | $1,958.85 | $2,448.56 | $2,448.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,722.91 / $8,931.98 / $21,487.10
| Facility | | $5,722.91 | $8,931.98 | $21,487.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,841.91 / $3,573.49 / $4,957.89
| Professional | | $2,841.91 | $3,573.49 | $4,957.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,959.41 / $8,165.98 / $16,918.98
| Facility | | $4,959.41 | $8,165.98 | $16,918.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,813.77 / $2,813.77 / $4,447.53
| Professional | | $2,813.77 | $2,813.77 | $4,447.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.56 / $4,284.97 / $6,733.54
| Facility | | $2,448.56 | $4,284.97 | $6,733.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.77 / $1,958.85 / $6,456.36
| Professional | | $1,248.77 | $1,958.85 | $6,456.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.77 / $2,448.56 / $5,616.75
| Professional | | $1,248.77 | $2,448.56 | $5,616.75 |