- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $2,238.72
| Professional | | $1,122.02 | $1,318.26 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $891.25 / $10,471.29
| Facility | | $380.19 | $891.25 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,090.30 / $4,897.79
| Professional | | $2,137.96 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,466.84 / $10,715.19
| Facility | | $3,162.28 | $4,466.84 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,630.78 / $5,370.32
| Professional | | $2,137.96 | $3,630.78 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $8,317.64
| Facility | | $3,467.37 | $4,265.80 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $4,897.79
| Professional | | $2,290.87 | $3,019.95 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $3,467.37
| Facility | | $1,318.26 | $2,089.30 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $6,760.83
| Professional | | $1,258.93 | $2,238.72 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,311.31 / $8,511.38
| Facility | | $1,445.44 | $3,311.31 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,238.72 / $4,570.88
| Professional | | $1,288.25 | $2,238.72 | $4,570.88 |