- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,584.89 / $1,905.46
| Professional | | $354.81 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,949.84 / $1,949.84
| Facility | | $1,905.46 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $1,949.84
| Professional | | $1,548.82 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,585.78 / $17,782.79
| Facility | | $4,265.80 | $7,585.78 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,818.38 / $3,981.07
| Professional | | $2,238.72 | $2,818.38 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,760.83 / $14,125.38
| Facility | | $4,677.35 | $6,760.83 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,715.35
| Professional | | $2,238.72 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,388.44 / $4,677.35
| Facility | | $1,949.84 | $3,388.44 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $5,128.61
| Professional | | $812.83 | $1,174.90 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,344.23
| Facility | | $1,949.84 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,621.81 / $4,168.69
| Professional | | $812.83 | $1,621.81 | $4,168.69 |