- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,344.23 / $7,244.36
| Professional | | $1,380.38 | $2,344.23 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,548.13 / $10,471.29
| Facility | | $3,467.37 | $3,548.13 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,467.37 / $4,073.80
| Professional | | $2,137.96 | $3,467.37 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,011.87 / $6,760.83
| Facility | | $4,365.16 | $5,011.87 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $2,511.89
| Professional | | $2,089.30 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $3,630.78 / $9,772.37
| Facility | | $60.26 | $3,630.78 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $6,456.54
| Professional | | $3,548.13 | $3,548.13 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,548.13 / $10,471.29
| Facility | | $3,467.37 | $3,548.13 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,467.37 / $4,073.80
| Professional | | $2,137.96 | $3,467.37 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $1,288.25 / $3,715.35
| Facility | | $269.15 | $1,288.25 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,019.95 / $5,011.87
| Professional | | $1,698.24 | $3,019.95 | $5,011.87 |