- 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 / $2,398.83
| Professional | | $1,202.26 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $12,022.64 / $26,302.68
| Facility | | $5,011.87 | $12,022.64 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $4,570.88
| Professional | | $1,949.84 | $2,884.03 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,570.88 / $10,964.78
| Facility | | $3,235.94 | $4,570.88 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,890.45 / $5,888.44
| Professional | | $2,570.40 | $3,890.45 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $8,511.38
| Facility | | $3,548.13 | $4,365.16 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $4,897.79
| Professional | | $2,344.23 | $3,311.31 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,041.74 / $3,548.13
| Facility | | $1,174.90 | $2,041.74 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,630.27 / $5,623.41
| Professional | | $1,548.82 | $2,630.27 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $2,137.96 / $4,265.80
| Facility | | $323.59 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,630.27 / $5,011.87
| Professional | | $1,513.56 | $2,630.27 | $5,011.87 |