- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,907.93 / $1,907.93 / $1,907.93
| Facility | | $1,907.93 | $1,907.93 | $1,907.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.39 / $1,786.54 / $1,907.93
| Professional | | $834.39 | $1,786.54 | $1,907.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.29 / $2,277.86 / $3,171.85
| Facility | | $1,951.29 | $2,277.86 | $3,171.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.29 / $2,163.96 / $2,277.86
| Professional | | $1,822.29 | $2,163.96 | $2,277.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.53 / $7,028.73 / $19,521.71
| Facility | | $1,473.53 | $7,028.73 | $19,521.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,640.75 / $2,799.20 / $3,353.75
| Professional | | $2,640.75 | $2,799.20 | $3,353.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,172.87 / $6,743.72 / $15,371.43
| Facility | | $4,172.87 | $6,743.72 | $15,371.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,640.75 / $2,640.75 / $2,717.60
| Professional | | $2,640.75 | $2,640.75 | $2,717.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $569.51 / $2,277.86 / $9,391.64
| Facility | | $569.51 | $2,277.86 | $9,391.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.98 / $956.38 / $2,287.37
| Professional | | $570.98 | $956.38 | $2,287.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.98 / $1,226.93 / $3,567.85
| Professional | | $570.98 | $1,226.93 | $3,567.85 |