- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Facility | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,951.21 / $4,168.69
| Professional | | $2,398.83 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,467.37 / $3,467.37
| Facility | | $3,388.44 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,467.37 / $3,467.37
| Professional | | $2,754.23 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $13,182.57 / $31,622.78
| Facility | | $9,120.11 | $13,182.57 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,011.87 / $7,079.46
| Professional | | $3,981.07 | $5,011.87 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,232.93 / $12,302.69 / $24,547.09
| Facility | | $10,232.93 | $12,302.69 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $6,606.93
| Professional | | $3,981.07 | $3,981.07 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,025.60 / $8,317.64
| Facility | | $2,238.72 | $6,025.60 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $9,120.11
| Professional | | $1,445.44 | $2,041.74 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,818.38 / $7,244.36
| Professional | | $1,445.44 | $2,818.38 | $7,244.36 |