- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Facility | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Professional | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,182.50 / $2,204.33 / $2,728.13
| Professional | | $2,182.50 | $2,204.33 | $2,728.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,171.61 / $3,326.71 / $6,374.25
| Facility | | $1,171.61 | $3,326.71 | $6,374.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.63 / $2,584.10 / $2,584.10
| Professional | | $99.63 | $2,584.10 | $2,584.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $178.04 / $182.99 / $3,941.49
| Facility | | $178.04 | $182.99 | $3,941.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.22 / $199.58 / $252.26
| Professional | | $136.22 | $199.58 | $252.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $2,326.37 / $2,326.37
| Professional | | $5.00 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.05 / $2,584.10 / $2,654.57
| Professional | | $2,248.05 | $2,584.10 | $2,654.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,280.76 / $2,280.76 / $2,280.76
| Facility | | $2,280.76 | $2,280.76 | $2,280.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.76 / $2,280.76 / $2,280.76
| Professional | | $2,280.76 | $2,280.76 | $2,280.76 |