- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,744.42 / $2,744.42 / $2,744.42
| Facility | | $2,744.42 | $2,744.42 | $2,744.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.72 / $2,744.42 / $3,160.17
| Professional | | $2,043.72 | $2,744.42 | $3,160.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.36 / $516.03 / $2,919.60
| Facility | | $189.36 | $516.03 | $2,919.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,799.20 / $2,249.00 / $2,249.00
| Professional | | $1,799.20 | $2,249.00 | $2,249.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,878.56 / $10,649.58 / $25,619.01
| Facility | | $5,878.56 | $10,649.58 | $25,619.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.35 / $4,260.59 / $5,666.69
| Professional | | $3,388.35 | $4,260.59 | $5,666.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,820.36 / $9,736.27 / $20,172.45
| Facility | | $5,820.36 | $9,736.27 | $20,172.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,354.80 / $3,354.80 / $5,302.69
| Professional | | $3,354.80 | $3,354.80 | $5,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.33 / $4,638.07 / $13,868.10
| Facility | | $1,808.33 | $4,638.07 | $13,868.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $2,627.64 / $6,697.27
| Professional | | $1,226.23 | $2,627.64 | $6,697.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,859.79 / $6,217.76
| Professional | | $1,226.23 | $1,859.79 | $6,217.76 |