- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $5,128.61
| Facility | | $3,162.28 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,412.54 / $3,388.44
| Professional | | $954.99 | $1,412.54 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $7,079.46
| Facility | | $1,949.84 | $3,388.44 | $7,079.46 |
- 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
- $1,380.38 / $3,630.78 / $7,585.78
| Facility | | $1,380.38 | $3,630.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,511.89 / $3,388.44
| Facility | | $1,148.15 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,344.23 / $2,344.23
| Professional | | $1,479.11 | $2,344.23 | $2,344.23 |
- 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
- $2,951.21 / $3,630.78 / $7,079.46
| Facility | | $2,951.21 | $3,630.78 | $7,079.46 |
- 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
- $741.31 / $741.31 / $1,862.09
| Professional | | $741.31 | $741.31 | $1,862.09 |