- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $2,691.53
| Professional | | $1,258.93 | $1,479.11 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,388.44 / $11,220.18
| Facility | | $1,479.11 | $3,388.44 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $5,011.87
| Professional | | $2,187.76 | $3,388.44 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,786.30 / $11,220.18
| Facility | | $2,951.21 | $4,786.30 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,630.78 / $5,623.41
| Professional | | $2,137.96 | $3,630.78 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,570.88 / $8,912.51
| Facility | | $3,630.78 | $4,570.88 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,235.94 / $5,128.61
| Professional | | $2,238.72 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,041.74 / $3,890.45
| Facility | | $1,318.26 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,570.40 / $11,220.18
| Professional | | $1,412.54 | $2,570.40 | $11,220.18 |
- 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
- $1,380.38 / $2,398.83 / $4,677.35
| Professional | | $1,380.38 | $2,398.83 | $4,677.35 |