- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,630.27 / $2,630.27
| Facility | | $1,778.28 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $5,623.41
| Professional | | $1,659.59 | $2,290.87 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $13,803.84
| Facility | | $3,890.45 | $3,890.45 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,344.23 / $3,715.35
| Professional | | $2,238.72 | $2,344.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $3,890.45
| Professional | | $2,344.23 | $2,344.23 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $3,311.31
| Professional | | $2,398.83 | $2,398.83 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,162.28 / $10,232.93
| Facility | | $2,041.74 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $30,199.52
| Professional | | $1,479.11 | $1,949.84 | $30,199.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $3,890.45
| Facility | | $2,511.89 | $3,090.30 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,905.46 / $2,884.03
| Professional | | $1,479.11 | $1,905.46 | $2,884.03 |