- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,564.42 / $2,564.42 / $2,564.42
| Facility | | $2,564.42 | $2,564.42 | $2,564.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.09 / $1,785.37 / $2,856.59
| Professional | | $986.09 | $1,785.37 | $2,856.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,541.92 / $2,675.70 / $2,846.23
| Facility | | $2,541.92 | $2,675.70 | $2,846.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,809.49 / $2,809.49 / $2,809.49
| Professional | | $2,809.49 | $2,809.49 | $2,809.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $2,217.07
| Facility | | $2,217.07 | $2,217.07 | $2,217.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $2,217.07 / $4,966.41
| Professional | | $1,618.46 | $2,217.07 | $4,966.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $986.09 / $2,748.55 / $16,018.84
| Facility | | $986.09 | $2,748.55 | $16,018.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.29 / $1,952.74 / $4,357.07
| Professional | | $1,018.29 | $1,952.74 | $4,357.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.44 / $2,236.05 / $2,728.36
| Facility | | $2.44 | $2,236.05 | $2,728.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.29 / $1,701.44 / $2,353.73
| Professional | | $1,134.29 | $1,701.44 | $2,353.73 |