- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,388.44 / $6,025.60
| Professional | | $2,818.38 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,388.44 / $25,118.86
| Facility | | $1,479.11 | $3,388.44 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $7,585.78 / $11,481.54
| Professional | | $5,011.87 | $7,585.78 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,715.19 / $25,703.96
| Facility | | $6,760.83 | $10,715.19 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,128.31 / $12,589.25
| Professional | | $4,897.79 | $8,128.31 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $10,232.93 / $19,952.62
| Facility | | $8,317.64 | $10,232.93 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,413.10 / $11,748.98
| Professional | | $5,128.61 | $7,413.10 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,365.16 / $8,709.64
| Facility | | $2,818.38 | $4,365.16 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,623.41 / $22,387.21
| Professional | | $3,235.94 | $5,623.41 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,311.31 / $8,511.38
| Facility | | $794.33 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,495.41 / $10,715.19
| Professional | | $3,235.94 | $5,495.41 | $10,715.19 |