- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,262.21 / $2,262.21 / $2,262.21
| Facility | | $2,262.21 | $2,262.21 | $2,262.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,799.70 / $2,262.21 / $2,496.16
| Professional | | $1,799.70 | $2,262.21 | $2,496.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $2,536.44
| Facility | | $1,747.16 | $1,747.16 | $2,536.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,131.25 / $3,131.25 / $3,914.06
| Professional | | $3,131.25 | $3,131.25 | $3,914.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,945.24 / $2,626.10 / $11,750.92
| Facility | | $1,945.24 | $2,626.10 | $11,750.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.30 / $1,700.26 / $2,682.96
| Professional | | $1,018.30 | $1,700.26 | $2,682.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,109.02 / $2,536.44 / $4,338.10
| Facility | | $2,109.02 | $2,536.44 | $4,338.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,178.81 / $2,572.16 / $4,847.13
| Professional | | $2,178.81 | $2,572.16 | $4,847.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.09 / $2,496.16 / $2,967.09
| Professional | | $2,132.09 | $2,496.16 | $2,967.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.04 / $1,699.21 / $3,565.12
| Professional | | $883.04 | $1,699.21 | $3,565.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,259.73 / $2,259.73 / $2,259.73
| Professional | | $2,259.73 | $2,259.73 | $2,259.73 |