- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,069.53 / $2,069.53 / $2,069.53
| Facility | | $2,069.53 | $2,069.53 | $2,069.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.14 / $1,915.41 / $2,069.53
| Professional | | $1,541.14 | $1,915.41 | $2,069.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,135.57 / $2,201.62 / $2,201.62
| Facility | | $2,135.57 | $2,201.62 | $2,201.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.30 / $2,201.62 / $2,201.62
| Professional | | $1,761.30 | $2,201.62 | $2,201.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,663.38 / $8,262.12 / $19,320.57
| Facility | | $5,663.38 | $8,262.12 | $19,320.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.92 / $3,212.62 / $4,227.04
| Professional | | $2,554.92 | $3,212.62 | $4,227.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,459.35 / $7,342.61 / $15,213.05
| Facility | | $4,459.35 | $7,342.61 | $15,213.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $2,529.63 / $3,998.40
| Professional | | $2,529.63 | $2,529.63 | $3,998.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,981.46 / $2,751.88 / $10,457.70
| Facility | | $1,981.46 | $2,751.88 | $10,457.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $1,402.43 / $4,671.39
| Professional | | $924.68 | $1,402.43 | $4,671.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.83 / $2,201.62 / $4,688.72
| Professional | | $1,122.83 | $2,201.62 | $4,688.72 |