- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $2,630.27
| Professional | | $1,230.27 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,762.47 / $13,803.84 / $30,199.52
| Facility | | $7,762.47 | $13,803.84 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $4,897.79
| Professional | | $2,187.76 | $3,388.44 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,677.35 / $11,220.18
| Facility | | $2,951.21 | $4,677.35 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,548.13 / $5,495.41
| Professional | | $2,137.96 | $3,548.13 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,466.84 / $8,912.51
| Facility | | $3,630.78 | $4,466.84 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,235.94 / $5,128.61
| Professional | | $2,238.72 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,949.84 / $3,801.89
| Facility | | $1,230.27 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $9,772.37
| Professional | | $1,380.38 | $2,454.71 | $9,772.37 |
- 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
- $1,348.96 / $2,344.23 / $4,677.35
| Professional | | $1,348.96 | $2,344.23 | $4,677.35 |