- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,348.96 / $2,454.71
| Professional | | $1,148.15 | $1,348.96 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,120.11 / $26,302.68
| Facility | | $5,495.41 | $9,120.11 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,162.28 / $4,677.35
| Professional | | $2,041.74 | $3,162.28 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,466.84 / $10,471.29
| Facility | | $2,754.23 | $4,466.84 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,388.44 / $5,248.07
| Professional | | $1,995.26 | $3,388.44 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $8,317.64
| Facility | | $3,388.44 | $4,265.80 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $4,786.30
| Professional | | $2,137.96 | $3,019.95 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,905.46 / $3,981.07
| Facility | | $1,230.27 | $1,905.46 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,344.23 / $11,748.98
| Professional | | $1,288.25 | $2,344.23 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,897.79 / $11,748.98
| Facility | | $1,445.44 | $4,897.79 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $4,265.80
| Professional | | $1,258.93 | $2,238.72 | $4,265.80 |