- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $8,317.64 / $8,317.64
| Facility | | $1,819.70 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $2,238.72
| Professional | | $1,230.27 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $5,370.32
| Facility | | $3,019.95 | $3,019.95 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,981.07 / $4,897.79
| Professional | | $1,862.09 | $3,981.07 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,630.27
| Professional | | $1,819.70 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,630.27
| Facility | | $1,862.09 | $1,862.09 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $4,897.79
| Facility | | $1,380.38 | $2,511.89 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,041.74 / $2,630.27
| Professional | | $79.43 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,235.94 / $7,244.36
| Facility | | $2,818.38 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,584.89 / $2,238.72
| Professional | | $1,479.11 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,951.21
| Facility | | $2,238.72 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $2,238.72
| Professional | | $776.25 | $776.25 | $2,238.72 |