- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,630.27
| Professional | | $1,202.26 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $9,120.11 / $26,302.68
| Facility | | $5,754.40 | $9,120.11 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,311.31 / $4,897.79
| Professional | | $2,137.96 | $3,311.31 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,677.35 / $11,220.18
| Facility | | $2,884.03 | $4,677.35 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,548.13 / $5,495.41
| Professional | | $2,089.30 | $3,548.13 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,466.84 / $8,709.64
| Facility | | $3,548.13 | $4,466.84 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,162.28 / $5,011.87
| Professional | | $2,238.72 | $3,162.28 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,949.84 / $3,801.89
| Facility | | $1,202.26 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,511.89 / $9,772.37
| Professional | | $1,348.96 | $2,511.89 | $9,772.37 |
- 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
- $1,318.26 / $2,344.23 / $4,570.88
| Professional | | $1,318.26 | $2,344.23 | $4,570.88 |