- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $2,137.96
| Professional | | $1,071.52 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $6,918.31 / $15,135.61
| Facility | | $2,511.89 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $4,073.80
| Professional | | $1,698.24 | $2,511.89 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,073.80 / $9,772.37
| Facility | | $2,884.03 | $4,073.80 | $9,772.37 |
- 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
- $3,162.28 / $3,981.07 / $7,762.47
| Facility | | $3,162.28 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,951.21 / $4,466.84
| Professional | | $2,137.96 | $2,951.21 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $3,467.37
| Facility | | $1,412.54 | $2,089.30 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,344.23 / $5,011.87
| Professional | | $1,380.38 | $2,344.23 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $8,511.38
| Facility | | $1,584.89 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,344.23 / $4,466.84
| Professional | | $1,348.96 | $2,344.23 | $4,466.84 |