- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $3,548.13
| Professional | | $1,905.46 | $2,344.23 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,943.28 / $26,915.35
| Facility | | $3,981.07 | $7,943.28 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,168.69 / $6,918.31
| Professional | | $2,884.03 | $4,168.69 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,606.93 / $15,848.93
| Facility | | $4,677.35 | $6,606.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,623.41 / $8,511.38
| Professional | | $3,715.35 | $5,623.41 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,309.57 / $12,302.69
| Facility | | $5,011.87 | $6,309.57 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,786.30 / $7,079.46
| Professional | | $3,548.13 | $4,786.30 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $5,495.41
| Facility | | $2,187.76 | $3,388.44 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,890.45 / $7,943.28
| Professional | | $2,290.87 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,981.07 / $7,762.47
| Professional | | $2,344.23 | $3,981.07 | $7,762.47 |