- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,492.85 / $1,492.85 / $1,492.85
| Facility | | $1,492.85 | $1,492.85 | $1,492.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.85 / $1,492.85 / $2,331.71
| Professional | | $1,492.85 | $1,492.85 | $2,331.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,081.63 / $6,581.93 / $15,884.95
| Facility | | $2,081.63 | $6,581.93 | $15,884.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.05 / $2,224.76 / $3,336.63
| Professional | | $1,469.05 | $2,224.76 | $3,336.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,730.66 / $4,412.03 / $5,681.86
| Facility | | $3,730.66 | $4,412.03 | $5,681.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,237.30 / $3,141.87 / $3,141.87
| Professional | | $2,237.30 | $3,141.87 | $3,141.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,619.96 / $1,808.29 / $2,511.26
| Facility | | $1,619.96 | $1,808.29 | $2,511.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.05 / $1,537.05 / $3,759.00
| Professional | | $1,537.05 | $1,537.05 | $3,759.00 |
- 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
- $2,766.35 / $2,766.35 / $2,904.67
| Professional | | $2,766.35 | $2,766.35 | $2,904.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,581.93 / $15,884.95 / $15,884.95
| Facility | | $6,581.93 | $15,884.95 | $15,884.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.65 / $1,826.37 / $3,336.63
| Professional | | $1,334.65 | $1,826.37 | $3,336.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.74 / $1,826.37 / $3,336.63
| Professional | | $1,443.74 | $1,826.37 | $3,336.63 |