- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.69 / $2,571.69 / $2,571.69
| Facility | | $2,571.69 | $2,571.69 | $2,571.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.11 / $2,571.69 / $3,131.74
| Professional | | $1,651.11 | $2,571.69 | $3,131.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,189.94 / $3,950.55 / $5,204.04
| Facility | | $3,189.94 | $3,950.55 | $5,204.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,960.97 / $3,516.15 / $3,701.21
| Professional | | $2,960.97 | $3,516.15 | $3,701.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $11,420.40 / $31,719.19
| Facility | | $2,017.28 | $11,420.40 | $31,719.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,290.75 / $4,548.20 / $5,449.25
| Professional | | $4,290.75 | $4,548.20 | $5,449.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,780.15 / $10,957.31 / $24,975.74
| Facility | | $6,780.15 | $10,957.31 | $24,975.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,290.75 / $4,290.75 / $4,415.60
| Professional | | $4,290.75 | $4,290.75 | $4,415.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,070.97 / $3,701.21 / $17,217.72
| Facility | | $1,070.97 | $3,701.21 | $17,217.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.74 / $1,788.09 / $3,759.69
| Professional | | $1,073.74 | $1,788.09 | $3,759.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.74 / $1,801.19 / $4,811.57
| Professional | | $1,073.74 | $1,801.19 | $4,811.57 |