- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $2,041.74
| Professional | | $1,023.29 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,398.83 / $3,548.13
| Facility | | $2,344.23 | $2,398.83 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $2,398.83
| Professional | | $1,949.84 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $8,912.51 / $21,379.62
| Facility | | $5,128.61 | $8,912.51 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,162.28 / $3,548.13
| Professional | | $2,818.38 | $3,162.28 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $8,912.51 / $16,982.44
| Facility | | $6,918.31 | $8,912.51 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,801.89
| Professional | | $2,818.38 | $2,818.38 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,398.83 / $4,365.16
| Facility | | $1,047.13 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $2,630.27
| Professional | | $724.44 | $1,071.52 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.98 / $1,412.54 / $2,951.21
| Facility | | $16.98 | $1,412.54 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,202.26 / $2,818.38
| Professional | | $724.44 | $1,202.26 | $2,818.38 |