- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.07 / $1,453.07 / $1,556.53
| Facility | | $1,453.07 | $1,453.07 | $1,556.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.07 / $1,453.07 / $1,453.07
| Professional | | $1,453.07 | $1,453.07 | $1,453.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.96 / $24.74 / $48.24
| Facility | | $18.96 | $24.74 | $48.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,673.23 / $3,346.46 / $3,588.63
| Professional | | $1,673.23 | $3,346.46 | $3,588.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.63 / $3,998.40 / $4,998.00
| Professional | | $2,529.63 | $3,998.40 | $4,998.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.97 / $2,615.53 / $10,457.70
| Facility | | $1,320.97 | $2,615.53 | $10,457.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.97 / $1,320.97 / $4,403.24
| Professional | | $1,320.97 | $1,320.97 | $4,403.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,641.94 / $4,535.34 / $6,055.42
| Facility | | $2,641.94 | $4,535.34 | $6,055.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,641.94 / $4,535.34 / $6,055.42
| Professional | | $2,641.94 | $4,535.34 | $6,055.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.92 / $1,320.97 / $4,403.24
| Professional | | $1,254.92 | $1,320.97 | $4,403.24 |