- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.71 / $1,454.71 / $1,454.71
| Facility | | $1,454.71 | $1,454.71 | $1,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.71 / $1,454.71 / $2,303.63
| Professional | | $1,454.71 | $1,454.71 | $2,303.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,028.45 / $7,988.76 / $15,475.07
| Facility | | $2,028.45 | $7,988.76 | $15,475.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.48 / $2,269.04 / $3,251.39
| Professional | | $1,472.48 | $2,269.04 | $3,251.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,635.35 / $4,299.32 / $5,536.71
| Facility | | $3,635.35 | $4,299.32 | $5,536.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.12 / $3,061.60 / $3,061.60
| Professional | | $2,180.12 | $3,061.60 | $3,061.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,578.56 / $2,253.75 / $2,447.07
| Facility | | $1,578.56 | $2,253.75 | $2,447.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.69 / $2,253.75 / $4,562.25
| Professional | | $1,915.69 | $2,253.75 | $4,562.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.68 / $2,695.68 / $2,830.46
| Professional | | $2,695.68 | $2,695.68 | $2,830.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,988.76 / $15,475.07 / $15,475.07
| Facility | | $7,988.76 | $15,475.07 | $15,475.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.56 / $1,779.69 / $3,251.39
| Professional | | $1,300.56 | $1,779.69 | $3,251.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.00 / $1,866.60 / $3,251.39
| Professional | | $1,446.00 | $1,866.60 | $3,251.39 |