- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,238.72 / $2,691.53
| Professional | | $1,862.09 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $4,677.35
| Facility | | $2,691.53 | $2,818.38 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $4,265.80
| Professional | | $3,467.37 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $9,120.11
| Facility | | $2,398.83 | $2,398.83 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,073.80 / $5,128.61
| Professional | | $3,981.07 | $4,073.80 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $7,244.36
| Facility | | $6,456.54 | $6,456.54 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $363.08 / $2,238.72
| Facility | | $331.13 | $363.08 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,230.27 / $2,570.40
| Professional | | $758.58 | $1,230.27 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.05 / $234.42 / $1,819.70
| Facility | | $19.05 | $234.42 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,318.26 / $2,951.21
| Professional | | $758.58 | $1,318.26 | $2,951.21 |