- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $5,011.87
| Facility | | $3,467.37 | $3,467.37 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $3,801.89
| Professional | | $1,047.13 | $1,584.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,630.78 / $6,918.31
| Facility | | $1,949.84 | $3,630.78 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,995.26 / $1,995.26
| Professional | | $1,949.84 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,073.80 / $7,585.78
| Facility | | $1,513.56 | $4,073.80 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $3,801.89
| Facility | | $1,949.84 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,041.74 / $2,398.83
| Professional | | $1,862.09 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $6,918.31
| Facility | | $2,884.03 | $3,801.89 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $2,041.74
| Professional | | $1,659.59 | $1,659.59 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,949.84
| Professional | | $812.83 | $812.83 | $1,949.84 |