- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,991.31 / $1,991.31 / $1,991.31
| Facility | | $1,991.31 | $1,991.31 | $1,991.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.31 / $1,991.31 / $2,347.96
| Professional | | $1,991.31 | $1,991.31 | $2,347.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,341.91 / $2,341.91 / $2,341.91
| Professional | | $2,341.91 | $2,341.91 | $2,341.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,744.42 / $3,018.88 / $3,049.36
| Professional | | $2,744.42 | $3,018.88 | $3,049.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,721.98 / $3,434.81 / $3,434.81
| Facility | | $1,721.98 | $3,434.81 | $3,434.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.98 / $3,434.81 / $5,296.55
| Professional | | $1,721.98 | $3,434.81 | $5,296.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.42 / $3,385.23 / $14,785.52
| Facility | | $1,620.42 | $3,385.23 | $14,785.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.83 / $1,848.22 / $3,122.55
| Professional | | $1,188.83 | $1,848.22 | $3,122.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,424.76 / $3,434.81 / $4,327.75
| Facility | | $3,424.76 | $3,434.81 | $4,327.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,109.96 / $4,059.32 / $7,076.27
| Professional | | $3,109.96 | $4,059.32 | $7,076.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,123.22 / $3,123.22 / $3,123.22
| Facility | | $3,123.22 | $3,123.22 | $3,123.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.83 / $1,557.81 / $2,118.58
| Professional | | $1,188.83 | $1,557.81 | $2,118.58 |