- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $2,818.38
| Professional | | $1,318.26 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,265.80 / $11,748.98
| Facility | | $1,862.09 | $4,265.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,630.78 / $5,248.07
| Professional | | $2,344.23 | $3,630.78 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,011.87 / $12,022.64
| Facility | | $3,162.28 | $5,011.87 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,890.45 / $6,025.60
| Professional | | $2,290.87 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,897.79 / $9,549.93
| Facility | | $3,890.45 | $4,897.79 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $5,495.41
| Professional | | $2,398.83 | $3,467.37 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $3,981.07
| Facility | | $1,318.26 | $2,089.30 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,691.53 / $10,471.29
| Professional | | $1,479.11 | $2,691.53 | $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 / $2,570.40 / $5,011.87
| Professional | | $1,445.44 | $2,570.40 | $5,011.87 |