- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $5,754.40
| Facility | | $3,981.07 | $3,981.07 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $4,365.16
| Professional | | $1,479.11 | $2,089.30 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,168.69 / $7,943.28
| Facility | | $2,238.72 | $4,168.69 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,238.72
| Professional | | $1,905.46 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $3,162.28
| Professional | | $2,089.30 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,981.07
| Facility | | $2,238.72 | $2,238.72 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,344.23 / $2,691.53
| Professional | | $2,137.96 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $77.62 / $77.62
| Professional | | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,168.69 / $7,943.28
| Facility | | $3,311.31 | $4,168.69 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,344.23
| Professional | | $1,905.46 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $2,691.53
| Professional | | $933.25 | $933.25 | $2,691.53 |