- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,168.69
| Facility | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,897.79 / $7,244.36
| Professional | | $3,630.78 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,165.95 / $6,456.54
| Facility | | $5,011.87 | $6,165.95 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,265.80 / $6,025.60
| Professional | | $2,089.30 | $4,265.80 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,606.93 / $6,606.93
| Professional | | $4,786.30 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $6,309.57
| Facility | | $3,981.07 | $3,981.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $3,981.07 / $10,964.78
| Professional | | $707.95 | $3,981.07 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $8,317.64 / $8,317.64
| Professional | | $2,570.40 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,165.95 / $6,456.54
| Facility | | $5,011.87 | $6,165.95 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $4,265.80 / $6,165.95
| Professional | | $2,089.30 | $4,265.80 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.27 / $537.03 / $4,073.80
| Facility | | $4.27 | $537.03 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $8,317.64
| Professional | | $2,089.30 | $3,388.44 | $8,317.64 |