- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,868.30 / $2,718.06
| Facility | | $1,323.35 | $1,868.30 | $2,718.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $1,588.01
| Professional | | $1,323.35 | $1,323.35 | $1,588.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.59 / $3,313.67 / $7,015.85
| Facility | | $1,284.59 | $3,313.67 | $7,015.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,389.52 / $6,148.12
| Professional | | $1,323.35 | $1,389.52 | $6,148.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,418.63 / $1,625.07 / $3,157.51
| Facility | | $1,418.63 | $1,625.07 | $3,157.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $1,392.52
| Facility | | $1,323.35 | $1,323.35 | $1,392.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $1,373.28
| Professional | | $1,323.35 | $1,323.35 | $1,373.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.35 / $2,068.63 / $8,090.00
| Facility | | $1,323.35 | $2,068.63 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $1,323.35
| Professional | | $1,323.35 | $1,323.35 | $1,323.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $1,531.65
| Professional | | $1,323.35 | $1,323.35 | $1,531.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,760.30 / $7,015.85 / $7,015.85
| Facility | | $1,760.30 | $7,015.85 | $7,015.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,402.75 / $6,148.12
| Professional | | $1,323.35 | $1,402.75 | $6,148.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,402.75 / $1,918.86
| Professional | | $1,323.35 | $1,402.75 | $1,918.86 |