- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,630.27 / $4,786.30
| Professional | | $2,238.72 | $2,630.27 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,265.80 / $19,952.62
| Facility | | $1,862.09 | $4,265.80 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,165.95 / $9,120.11
| Professional | | $3,981.07 | $6,165.95 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $8,709.64 / $20,417.38
| Facility | | $5,370.32 | $8,709.64 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,606.93 / $10,232.93
| Professional | | $3,890.45 | $6,606.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $8,317.64 / $16,218.10
| Facility | | $6,606.93 | $8,317.64 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,888.44 / $9,332.54
| Professional | | $4,168.69 | $5,888.44 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,388.44 / $6,760.83
| Facility | | $2,238.72 | $3,388.44 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,897.79 / $18,197.01
| Professional | | $2,511.89 | $4,897.79 | $18,197.01 |
- 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
- $2,454.71 / $4,570.88 / $8,511.38
| Professional | | $2,454.71 | $4,570.88 | $8,511.38 |