- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $2,344.23
| Professional | | $1,047.13 | $1,230.27 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $13,489.63 / $26,302.68
| Facility | | $6,760.83 | $13,489.63 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,884.03 / $4,265.80
| Professional | | $1,862.09 | $2,884.03 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,981.07 / $9,549.93
| Facility | | $2,511.89 | $3,981.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,090.30 / $4,786.30
| Professional | | $1,819.70 | $3,090.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,890.45 / $7,585.78
| Facility | | $3,090.30 | $3,890.45 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,754.23 / $4,365.16
| Professional | | $1,905.46 | $2,754.23 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,584.89 / $3,311.31
| Facility | | $1,000.00 | $1,584.89 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,187.76 / $8,511.38
| Professional | | $1,174.90 | $2,187.76 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,467.37 / $6,456.54
| Facility | | $1,230.27 | $3,467.37 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,041.74 / $3,890.45
| Professional | | $1,148.15 | $2,041.74 | $3,890.45 |