- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,229.73 / $1,229.73 / $1,317.29
| Facility | | $1,229.73 | $1,229.73 | $1,317.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.73 / $1,229.73 / $1,229.73
| Professional | | $1,229.73 | $1,229.73 | $1,229.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.43 / $296.51 / $573.54
| Facility | | $225.43 | $296.51 | $573.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,690.48 / $2,945.94 / $3,055.67
| Professional | | $2,690.48 | $2,945.94 | $3,055.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.12 / $4,230.14 / $4,769.84
| Professional | | $3,384.12 | $4,230.14 | $4,769.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,229.73 / $2,336.48 / $8,850.29
| Facility | | $1,229.73 | $2,336.48 | $8,850.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.93 / $1,117.93 / $5,384.71
| Professional | | $1,117.93 | $1,117.93 | $5,384.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,235.86 / $2,608.51 / $4,359.93
| Facility | | $2,235.86 | $2,608.51 | $4,359.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.86 / $3,838.23 / $4,769.84
| Professional | | $2,235.86 | $3,838.23 | $4,769.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.96 / $2,179.96 / $3,800.97
| Professional | | $2,179.96 | $2,179.96 | $3,800.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.04 / $1,117.93 / $3,633.28
| Professional | | $1,062.04 | $1,117.93 | $3,633.28 |