- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.80 / $1,444.80 / $1,444.80
| Facility | | $1,444.80 | $1,444.80 | $1,444.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.91 / $1,444.80 / $1,444.80
| Professional | | $1,075.91 | $1,444.80 | $1,444.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.17 / $1,537.02 / $1,537.02
| Facility | | $1,460.17 | $1,537.02 | $1,537.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.61 / $1,537.02 / $1,537.02
| Professional | | $1,229.61 | $1,537.02 | $1,537.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,592.32 / $5,606.68 / $13,487.62
| Facility | | $3,592.32 | $5,606.68 | $13,487.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.07 / $2,243.33 / $3,112.42
| Professional | | $1,784.07 | $2,243.33 | $3,112.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,113.06 / $5,125.85 / $10,620.18
| Facility | | $3,113.06 | $5,125.85 | $10,620.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.40 / $1,766.40 / $2,792.03
| Professional | | $1,766.40 | $1,766.40 | $2,792.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,537.02 / $2,689.79 / $4,226.81
| Facility | | $1,537.02 | $2,689.79 | $4,226.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.88 / $1,229.61 / $4,052.81
| Professional | | $783.88 | $1,229.61 | $4,052.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.51 / $922.21 / $3,273.33
| Professional | | $768.51 | $922.21 | $3,273.33 |