- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.07 / $1,552.07 / $1,552.07
| Facility | | $1,552.07 | $1,552.07 | $1,552.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.72 / $1,552.07 / $1,669.30
| Professional | | $959.72 | $1,552.07 | $1,669.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,913.51 / $2,233.75 / $3,110.44
| Facility | | $1,913.51 | $2,233.75 | $3,110.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.00 / $2,122.06 / $2,233.75
| Professional | | $1,787.00 | $2,122.06 | $2,233.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.07 / $6,892.17 / $19,142.41
| Facility | | $1,306.07 | $6,892.17 | $19,142.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.75 / $2,745.14 / $3,288.98
| Professional | | $2,589.75 | $2,745.14 | $3,288.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,091.80 / $6,612.70 / $15,072.78
| Facility | | $4,091.80 | $6,612.70 | $15,072.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.75 / $2,589.75 / $2,664.80
| Professional | | $2,589.75 | $2,589.75 | $2,664.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $693.40 / $2,233.75 / $11,140.65
| Facility | | $693.40 | $2,233.75 | $11,140.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.18 / $1,144.66 / $2,299.21
| Professional | | $695.18 | $1,144.66 | $2,299.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.18 / $1,144.66 / $2,903.88
| Professional | | $695.18 | $1,144.66 | $2,903.88 |