- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,161.71 / $2,161.71 / $3,714.65
| Facility | | $2,161.71 | $2,161.71 | $3,714.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.79 / $1,232.50 / $1,645.42
| Professional | | $907.79 | $1,232.50 | $1,645.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.58 / $1,364.62 / $1,971.15
| Professional | | $1,173.58 | $1,364.62 | $1,971.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.63 / $1,462.24 / $2,275.92
| Professional | | $1,155.63 | $1,462.24 | $2,275.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.30 / $1,466.03 / $2,248.98
| Professional | | $1,138.30 | $1,466.03 | $2,248.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,161.71 / $3,714.65 / $22,149.21
| Facility | | $2,161.71 | $3,714.65 | $22,149.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.79 / $1,232.50 / $1,912.20
| Professional | | $907.79 | $1,232.50 | $1,912.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,831.32 / $11,831.32 / $11,831.32
| Facility | | $11,831.32 | $11,831.32 | $11,831.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.14 / $1,364.52 / $2,076.29
| Professional | | $1,105.14 | $1,364.52 | $2,076.29 |