- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,247.06 / $1,247.06 / $1,247.06
| Facility | | $1,247.06 | $1,247.06 | $1,247.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.70 / $1,247.06 / $3,016.17
| Professional | | $1,051.70 | $1,247.06 | $3,016.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.14 / $2,836.70 / $3,545.88
| Professional | | $2,179.14 | $2,836.70 | $3,545.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,573.06 / $2,056.76 / $3,268.18
| Facility | | $1,573.06 | $2,056.76 | $3,268.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.96 / $2,541.17 / $9,307.52
| Professional | | $1,182.96 | $2,541.17 | $9,307.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,871.07 / $3,086.01 / $22,682.53
| Facility | | $1,871.07 | $3,086.01 | $22,682.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,871.07 / $2,610.21 / $3,376.01
| Professional | | $1,871.07 | $2,610.21 | $3,376.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.33 / $2,116.57 / $2,489.92
| Professional | | $1,538.33 | $2,116.57 | $2,489.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $25,733.64
| Facility | | $5,357.00 | $5,357.00 | $25,733.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.09 / $2,539.17 / $3,437.81
| Professional | | $1,331.09 | $2,539.17 | $3,437.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,470.10 / $3,022.20 / $3,022.20
| Professional | | $2,470.10 | $3,022.20 | $3,022.20 |