- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,698.24 / $2,630.27
| Professional | | $1,380.38 | $1,698.24 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $22,908.68 / $44,668.36
| Facility | | $9,549.93 | $22,908.68 | $44,668.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,019.95 / $4,786.30
| Professional | | $2,041.74 | $3,019.95 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,570.88 / $10,715.19
| Facility | | $3,162.28 | $4,570.88 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,890.45 / $5,754.40
| Professional | | $2,511.89 | $3,890.45 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,365.16 / $8,511.38
| Facility | | $3,467.37 | $4,365.16 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $4,897.79
| Professional | | $2,398.83 | $3,235.94 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,511.89 / $3,981.07
| Facility | | $1,737.80 | $2,511.89 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $5,495.41
| Professional | | $1,698.24 | $2,884.03 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,884.03 / $5,370.32
| Professional | | $1,737.80 | $2,884.03 | $5,370.32 |