- 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
- $1,288.25 / $1,737.80 / $2,570.40
| Professional | | $1,288.25 | $1,737.80 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,235.94 / $4,677.35
| Facility | | $3,162.28 | $3,235.94 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $3,235.94
| Professional | | $2,570.40 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $12,022.64 / $28,840.32
| Facility | | $6,760.83 | $12,022.64 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,265.80 / $4,786.30
| Professional | | $3,715.35 | $4,265.80 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,332.54 / $12,022.64 / $22,908.68
| Facility | | $9,332.54 | $12,022.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $5,128.61
| Professional | | $3,715.35 | $3,715.35 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,235.94 / $6,606.93
| Facility | | $1,288.25 | $3,235.94 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,445.44 / $3,388.44
| Professional | | $977.24 | $1,445.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.91 / $1,445.44 / $3,981.07
| Facility | | $22.91 | $1,445.44 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,548.82 / $3,981.07
| Professional | | $1,071.52 | $1,548.82 | $3,981.07 |