- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,089.30 / $3,715.35
| Professional | | $1,778.28 | $2,089.30 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,265.80 / $15,848.93
| Facility | | $1,862.09 | $4,265.80 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,897.79 / $7,244.36
| Professional | | $3,162.28 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $16,595.87
| Facility | | $4,365.16 | $6,918.31 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,248.07 / $8,128.31
| Professional | | $3,090.30 | $5,248.07 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,606.93 / $12,882.50
| Facility | | $5,370.32 | $6,606.93 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,786.30 / $7,585.78
| Professional | | $3,311.31 | $4,786.30 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,691.53 / $5,495.41
| Facility | | $1,737.80 | $2,691.53 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,548.13 / $14,454.40
| Professional | | $1,949.84 | $3,548.13 | $14,454.40 |
- 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
- $1,949.84 / $3,388.44 / $6,606.93
| Professional | | $1,949.84 | $3,388.44 | $6,606.93 |