- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $4,168.69
| Professional | | $1,949.84 | $2,344.23 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $14,454.40 / $41,686.94
| Facility | | $7,762.47 | $14,454.40 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,370.32 / $7,943.28
| Professional | | $3,467.37 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $7,413.10 / $17,782.79
| Facility | | $4,677.35 | $7,413.10 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,623.41 / $8,912.51
| Professional | | $3,388.44 | $5,623.41 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,079.46 / $14,125.38
| Facility | | $5,754.40 | $7,079.46 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,128.61 / $8,128.31
| Professional | | $3,548.13 | $5,128.61 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,162.28 / $6,025.60
| Facility | | $1,949.84 | $3,162.28 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,981.07 / $17,782.79
| Professional | | $2,187.76 | $3,981.07 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,311.31 / $8,511.38
| Facility | | $794.33 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,801.89 / $7,413.10
| Professional | | $2,187.76 | $3,801.89 | $7,413.10 |