- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,025.61 / $2,025.61 / $2,025.61
| Facility | | $2,025.61 | $2,025.61 | $2,025.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.75 / $1,812.18 / $2,025.61
| Professional | | $857.75 | $1,812.18 | $2,025.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,071.65 / $2,418.36 / $3,367.49
| Facility | | $2,071.65 | $2,418.36 | $3,367.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.69 / $2,297.44 / $2,418.36
| Professional | | $1,934.69 | $2,297.44 | $2,418.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.30 / $7,462.21 / $20,725.65
| Facility | | $1,167.30 | $7,462.21 | $20,725.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,803.50 / $2,971.71 / $3,560.45
| Professional | | $2,803.50 | $2,971.71 | $3,560.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,430.22 / $7,159.62 / $16,319.41
| Facility | | $4,430.22 | $7,159.62 | $16,319.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,803.50 / $2,803.50 / $2,885.20
| Professional | | $2,803.50 | $2,803.50 | $2,885.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $619.72 / $2,418.36 / $9,793.70
| Facility | | $619.72 | $2,418.36 | $9,793.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.32 / $1,042.68 / $2,428.46
| Professional | | $621.32 | $1,042.68 | $2,428.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.32 / $1,040.71 / $2,490.91
| Professional | | $621.32 | $1,040.71 | $2,490.91 |