- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,437.19 / $2,437.19 / $2,437.19
| Facility | | $2,437.19 | $2,437.19 | $2,437.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.34 / $2,437.19 / $2,501.19
| Professional | | $1,311.34 | $2,437.19 | $2,501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,492.58 / $2,909.74 / $4,051.72
| Facility | | $2,492.58 | $2,909.74 | $4,051.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,327.79 / $2,764.25 / $2,909.74
| Professional | | $2,327.79 | $2,764.25 | $2,909.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $8,977.82 / $24,935.15
| Facility | | $2,050.41 | $8,977.82 | $24,935.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,373.13 / $3,575.51 / $4,283.87
| Professional | | $3,373.13 | $3,575.51 | $4,283.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,330.03 / $8,613.78 / $19,633.98
| Facility | | $5,330.03 | $8,613.78 | $19,633.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,373.13 / $3,373.13 / $3,471.20
| Professional | | $3,373.13 | $3,373.13 | $3,471.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $947.42 / $2,909.74 / $15,093.28
| Facility | | $947.42 | $2,909.74 | $15,093.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.88 / $1,526.88 / $3,072.34
| Professional | | $949.88 | $1,526.88 | $3,072.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.88 / $1,451.63 / $3,049.07
| Professional | | $949.88 | $1,451.63 | $3,049.07 |