- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $2,398.83
| Professional | | $1,202.26 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,818.38 / $4,168.69
| Facility | | $2,754.23 | $2,818.38 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $2,818.38
| Professional | | $2,290.87 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $10,715.19 / $25,703.96
| Facility | | $6,165.95 | $10,715.19 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,715.35 / $4,168.69
| Professional | | $3,311.31 | $3,715.35 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $10,232.93 / $19,952.62
| Facility | | $8,128.31 | $10,232.93 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $4,466.84
| Professional | | $3,311.31 | $3,311.31 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,818.38 / $5,128.61
| Facility | | $1,202.26 | $2,818.38 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $3,090.30
| Professional | | $851.14 | $1,258.93 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.42 / $1,659.59 / $3,467.37
| Facility | | $20.42 | $1,659.59 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,412.54 / $3,311.31
| Professional | | $851.14 | $1,412.54 | $3,311.31 |