- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.01 / $2,016.01 / $2,016.01
| Facility | | $2,016.01 | $2,016.01 | $2,016.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.01 / $2,016.01 / $2,377.09
| Professional | | $2,016.01 | $2,016.01 | $2,377.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,778.48 / $3,056.32 / $3,087.19
| Professional | | $2,778.48 | $3,056.32 | $3,087.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $3,477.42 / $3,477.42
| Facility | | $1,743.07 | $3,477.42 | $3,477.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,382.69 / $3,818.25 / $5,362.26
| Professional | | $3,382.69 | $3,818.25 | $5,362.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.15 / $3,427.22 / $14,630.94
| Facility | | $1,650.15 | $3,427.22 | $14,630.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.58 / $1,855.57 / $2,628.56
| Professional | | $1,203.58 | $1,855.57 | $2,628.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.26 / $3,477.42 / $4,381.41
| Facility | | $3,467.26 | $3,477.42 | $4,381.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,891.42 / $4,109.68 / $7,164.05
| Professional | | $2,891.42 | $4,109.68 | $7,164.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.58 / $1,577.14 / $2,144.53
| Professional | | $1,203.58 | $1,577.14 | $2,144.53 |