- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,779.77 / $1,779.77 / $1,779.77
| Facility | | $1,779.77 | $1,779.77 | $1,779.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.04 / $1,779.77 / $5,140.93
| Professional | | $1,498.04 | $1,779.77 | $5,140.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,093.65 / $4,027.17 / $5,033.96
| Professional | | $3,093.65 | $4,027.17 | $5,033.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.92 / $3,071.36 / $4,857.42
| Facility | | $2,151.92 | $3,071.36 | $4,857.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.32 / $3,793.97 / $18,361.93
| Professional | | $1,987.32 | $3,793.97 | $18,361.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.03 / $4,114.85 / $5,611.49
| Facility | | $2,801.03 | $4,114.85 | $5,611.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,801.03 / $4,016.86 / $4,878.42
| Professional | | $2,801.03 | $4,016.86 | $4,878.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.90 / $3,084.34 / $3,562.48
| Professional | | $2,243.90 | $3,084.34 | $3,562.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.32 / $3,195.81 / $4,971.26
| Professional | | $1,987.32 | $3,195.81 | $4,971.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,534.10 / $4,324.10 / $4,324.10
| Professional | | $3,534.10 | $4,324.10 | $4,324.10 |