- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $16,218.10
| Professional | | $1,047.13 | $1,778.28 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,951.21
| Professional | | $2,454.71 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $2,454.71 / $3,162.28
| Professional | | $60.26 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,951.21 / $5,128.61
| Facility | | $2,511.89 | $2,951.21 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $3,630.78
| Professional | | $1,905.46 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,388.44 / $3,630.78
| Professional | | $2,884.03 | $3,388.44 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $4,365.16
| Professional | | $2,454.71 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $2,290.87
| Facility | | $851.14 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $2,290.87
| Professional | | $1,258.93 | $1,621.81 | $2,290.87 |