- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $2,884.03
| Professional | | $1,288.25 | $1,548.82 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,388.44 / $11,748.98
| Facility | | $1,479.11 | $3,388.44 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,548.13 / $5,248.07
| Professional | | $2,290.87 | $3,548.13 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,897.79 / $11,748.98
| Facility | | $3,090.30 | $4,897.79 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,715.35 / $5,888.44
| Professional | | $2,238.72 | $3,715.35 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,786.30 / $9,332.54
| Facility | | $3,801.89 | $4,786.30 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $5,370.32
| Professional | | $2,344.23 | $3,388.44 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,041.74 / $3,981.07
| Facility | | $1,318.26 | $2,041.74 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,754.23 / $10,471.29
| Professional | | $1,445.44 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,311.31 / $8,511.38
| Facility | | $794.33 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,511.89 / $4,897.79
| Professional | | $1,445.44 | $2,511.89 | $4,897.79 |