- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,781.01 / $1,781.01 / $1,781.01
| Facility | | $1,781.01 | $1,781.01 | $1,781.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.24 / $1,613.57 / $1,781.01
| Professional | | $732.24 | $1,613.57 | $1,781.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,821.49 / $2,126.34 / $2,960.86
| Facility | | $1,821.49 | $2,126.34 | $2,960.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.07 / $2,020.02 / $2,126.34
| Professional | | $1,701.07 | $2,020.02 | $2,126.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.64 / $6,561.12 / $18,222.93
| Facility | | $1,020.64 | $6,561.12 | $18,222.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.25 / $2,613.17 / $3,130.87
| Professional | | $2,465.25 | $2,613.17 | $3,130.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,895.26 / $6,295.07 / $14,348.78
| Facility | | $3,895.26 | $6,295.07 | $14,348.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.25 / $2,465.25 / $2,536.80
| Professional | | $2,465.25 | $2,465.25 | $2,536.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $529.04 / $2,118.69 / $8,461.77
| Facility | | $529.04 | $2,118.69 | $8,461.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.40 / $888.43 / $2,135.23
| Professional | | $530.40 | $888.43 | $2,135.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.95 / $1,486.30 / $3,414.48
| Professional | | $622.95 | $1,486.30 | $3,414.48 |