- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,437.27 / $2,437.27 / $2,437.27
| Facility | | $2,437.27 | $2,437.27 | $2,437.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.21 / $2,437.27 / $2,924.72
| Professional | | $2,345.21 | $2,437.27 | $2,924.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,392.27 / $3,087.80 / $3,744.63
| Facility | | $2,392.27 | $3,087.80 | $3,744.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.04 / $2,386.46 / $2,934.23
| Professional | | $1,215.04 | $2,386.46 | $2,934.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,723.40 / $2,778.70 / $2,778.70
| Professional | | $2,723.40 | $2,778.70 | $2,778.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.01 / $2,416.31 / $4,978.13
| Professional | | $288.01 | $2,416.31 | $4,978.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,530.94 / $2,530.94 / $2,530.94
| Professional | | $2,530.94 | $2,530.94 | $2,530.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $3,744.63 / $3,744.63
| Facility | | $100.00 | $3,744.63 | $3,744.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.57 / $1,511.44 / $2,430.07
| Professional | | $1,186.57 | $1,511.44 | $2,430.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.65 / $1,944.06 / $2,530.94
| Professional | | $1,187.65 | $1,944.06 | $2,530.94 |