- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,543.56 / $2,543.56 / $2,543.56
| Facility | | $2,543.56 | $2,543.56 | $2,543.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.65 / $2,206.02 / $2,543.56
| Professional | | $1,060.65 | $2,206.02 | $2,543.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,601.37 / $3,036.73 / $4,228.56
| Facility | | $2,601.37 | $3,036.73 | $4,228.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.38 / $2,884.89 / $3,036.73
| Professional | | $2,429.38 | $2,884.89 | $3,036.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,964.43 / $9,369.92 / $26,024.16
| Facility | | $1,964.43 | $9,369.92 | $26,024.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,520.50 / $3,731.73 / $4,471.04
| Professional | | $3,520.50 | $3,731.73 | $4,471.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,562.81 / $8,989.98 / $20,491.46
| Facility | | $5,562.81 | $8,989.98 | $20,491.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,520.50 / $3,520.50 / $3,622.80
| Professional | | $3,520.50 | $3,520.50 | $3,622.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $766.31 / $3,036.73 / $12,160.93
| Facility | | $766.31 | $3,036.73 | $12,160.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.29 / $1,286.88 / $3,049.43
| Professional | | $768.29 | $1,286.88 | $3,049.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.29 / $1,286.88 / $3,049.43
| Professional | | $768.29 | $1,286.88 | $3,049.43 |