- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,586.18 / $7,586.18 / $7,586.18
| Facility | | $7,586.18 | $7,586.18 | $7,586.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.60 / $1,134.71 / $1,134.71
| Professional | | $1,099.60 | $1,134.71 | $1,134.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,833.93 / $2,833.93 / $5,067.06
| Facility | | $2,833.93 | $2,833.93 | $5,067.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.84 / $935.84 / $935.84
| Professional | | $935.84 | $935.84 | $935.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.95 / $3,828.78 / $4,588.14
| Professional | | $1,743.95 | $3,828.78 | $4,588.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,134.71 / $1,569.56 / $2,848.56
| Facility | | $1,134.71 | $1,569.56 | $2,848.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.95 / $2,092.73 / $2,441.53
| Professional | | $1,743.95 | $2,092.73 | $2,441.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.95 / $1,953.22 / $3,051.91
| Facility | | $1,743.95 | $1,953.22 | $3,051.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,134.71 / $2,214.82 / $3,836.69
| Facility | | $1,134.71 | $2,214.82 | $3,836.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.35 / $1,918.35 / $2,477.28
| Professional | | $1,918.35 | $1,918.35 | $2,477.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.20 / $5,147.97 / $6,369.43
| Facility | | $3,297.20 | $5,147.97 | $6,369.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.26 / $3,108.12 / $5,484.61
| Professional | | $2,203.26 | $3,108.12 | $5,484.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.32 / $491.32 / $1,743.95
| Professional | | $491.32 | $491.32 | $1,743.95 |