- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $5,679.80 / $7,944.75
| Facility | | $2,919.60 | $5,679.80 | $7,944.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.94 / $2,248.09 / $2,832.01
| Professional | | $1,926.94 | $2,248.09 | $2,832.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,503.52 / $3,503.52 / $3,503.52
| Facility | | $3,503.52 | $3,503.52 | $3,503.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,506.42 / $5,302.69 / $6,628.37
| Professional | | $3,506.42 | $5,302.69 | $6,628.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.66 / $3,941.46 / $5,284.48
| Professional | | $2,481.66 | $3,941.46 | $5,284.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $3,767.54 / $7,474.18
| Facility | | $2,919.60 | $3,767.54 | $7,474.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.76 / $1,858.33 / $11,208.30
| Professional | | $1,751.76 | $1,858.33 | $11,208.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,503.52 / $4,087.44 / $6,398.56
| Facility | | $3,503.52 | $4,087.44 | $6,398.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,503.52 / $5,109.30 / $6,398.56
| Professional | | $3,503.52 | $5,109.30 | $6,398.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $5,211.49
| Professional | | $2,919.60 | $2,919.60 | $5,211.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.76 / $1,751.76 / $6,364.73
| Professional | | $1,751.76 | $1,751.76 | $6,364.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $2,919.60
| Professional | | $2,919.60 | $2,919.60 | $2,919.60 |