- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.47 / $2,041.47 / $2,041.47
| Facility | | $2,041.47 | $2,041.47 | $2,041.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.89 / $1,652.16 / $2,041.47
| Professional | | $920.89 | $1,652.16 | $2,041.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,087.87 / $2,437.29 / $3,393.87
| Facility | | $2,087.87 | $2,437.29 | $3,393.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.83 / $2,315.42 / $2,437.29
| Professional | | $1,949.83 | $2,315.42 | $2,437.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,576.65 / $7,520.14 / $20,886.56
| Facility | | $1,576.65 | $7,520.14 | $20,886.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,825.63 / $2,995.16 / $3,588.54
| Professional | | $2,825.63 | $2,995.16 | $3,588.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,464.62 / $7,215.21 / $16,446.11
| Facility | | $4,464.62 | $7,215.21 | $16,446.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,825.63 / $2,825.63 / $2,907.60
| Professional | | $2,825.63 | $2,825.63 | $2,907.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $622.39 / $2,437.29 / $9,757.10
| Facility | | $622.39 | $2,437.29 | $9,757.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.00 / $1,046.76 / $2,447.48
| Professional | | $624.00 | $1,046.76 | $2,447.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.00 / $1,045.20 / $2,447.48
| Professional | | $624.00 | $1,045.20 | $2,447.48 |