- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.92 / $1,427.92 / $1,427.92
| Facility | | $1,427.92 | $1,427.92 | $1,427.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.33 / $1,427.92 / $1,427.92
| Professional | | $1,063.33 | $1,427.92 | $1,427.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,443.11 / $1,519.06 / $1,519.06
| Facility | | $1,443.11 | $1,519.06 | $1,519.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.25 / $1,519.06 / $1,519.06
| Professional | | $1,215.25 | $1,519.06 | $1,519.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,550.23 / $5,540.98 / $13,329.59
| Facility | | $3,550.23 | $5,540.98 | $13,329.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.79 / $2,216.58 / $3,075.30
| Professional | | $1,762.79 | $2,216.58 | $3,075.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,076.58 / $5,065.79 / $10,495.74
| Facility | | $3,076.58 | $5,065.79 | $10,495.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.34 / $1,745.34 / $2,758.73
| Professional | | $1,745.34 | $1,745.34 | $2,758.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.06 / $2,658.36 / $4,177.42
| Facility | | $1,519.06 | $2,658.36 | $4,177.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.72 / $1,215.25 / $4,005.46
| Professional | | $774.72 | $1,215.25 | $4,005.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.01 / $911.44 / $3,223.14
| Professional | | $638.01 | $911.44 | $3,223.14 |