- 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 / $1,258.93 / $2,041.74
| Professional | | $1,047.13 | $1,258.93 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $6,606.93 / $15,135.61
| Facility | | $3,235.94 | $6,606.93 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,454.71 / $3,981.07
| Professional | | $1,659.59 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,981.07 / $9,332.54
| Facility | | $2,818.38 | $3,981.07 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $5,011.87
| Professional | | $2,187.76 | $3,388.44 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,801.89 / $7,413.10
| Facility | | $3,019.95 | $3,801.89 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $4,265.80
| Professional | | $2,041.74 | $2,818.38 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $3,467.37
| Facility | | $1,380.38 | $2,041.74 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,238.72 / $4,897.79
| Professional | | $1,348.96 | $2,238.72 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,238.72 / $4,265.80
| Professional | | $1,318.26 | $2,238.72 | $4,265.80 |