- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.00 / $4,376.00 / $7,593.00
| Facility | | $1,181.00 | $4,376.00 | $7,593.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.62 / $1,377.62 / $1,465.92
| Professional | | $1,377.62 | $1,377.62 | $1,465.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.04 / $2,772.54 / $3,635.01
| Professional | | $2,191.04 | $2,772.54 | $3,635.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,170.98 / $1,337.61 / $2,526.96
| Facility | | $1,170.98 | $1,337.61 | $2,526.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.61 / $1,337.61 / $1,337.61
| Professional | | $1,337.61 | $1,337.61 | $1,337.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $5.00
| Professional | | $5.00 | $5.00 | $5.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.00 / $4,086.00 / $7,778.00
| Facility | | $1,172.00 | $4,086.00 | $7,778.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.14 / $1,939.66 / $4,093.20
| Professional | | $1,395.14 | $1,939.66 | $4,093.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,731.08 / $10,684.44 / $10,684.44
| Facility | | $8,731.08 | $10,684.44 | $10,684.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,195.84 / $12,472.05 / $12,472.05
| Professional | | $11,195.84 | $12,472.05 | $12,472.05 |