- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $4,265.80
| Professional | | $2,570.40 | $3,388.44 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,365.16 / $5,248.07
| Facility | | $3,162.28 | $4,365.16 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,162.28 / $4,073.80
| Professional | | $1,659.59 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,365.16 / $4,365.16
| Professional | | $3,801.89 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,715.35
| Facility | | $3,630.78 | $3,630.78 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $3,630.78 / $7,079.46
| Professional | | $436.52 | $3,630.78 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,265.80 / $4,265.80
| Professional | | $1,698.24 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,365.16 / $5,248.07
| Facility | | $3,162.28 | $4,365.16 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,311.31 / $4,365.16
| Professional | | $1,659.59 | $3,311.31 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.51 / $354.81 / $2,754.23
| Facility | | $2.51 | $354.81 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,630.27 / $4,365.16
| Professional | | $1,659.59 | $2,630.27 | $4,365.16 |