- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,316.56 / $1,316.56 / $1,316.56
| Facility | | $1,316.56 | $1,316.56 | $1,316.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.33 / $1,402.21 / $2,128.44
| Professional | | $1,276.33 | $1,402.21 | $2,128.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $370.96 / $830.40 / $10,812.28
| Facility | | $370.96 | $830.40 | $10,812.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,553.82 / $4,079.96 / $5,186.47
| Professional | | $2,553.82 | $4,079.96 | $5,186.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,252.83 / $4,615.30 / $11,102.72
| Facility | | $3,252.83 | $4,615.30 | $11,102.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.71 / $3,881.64 / $5,764.83
| Professional | | $2,436.71 | $3,881.64 | $5,764.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,957.12 / $4,219.49 / $8,742.29
| Facility | | $2,957.12 | $4,219.49 | $8,742.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.13 / $3,470.45 / $5,286.68
| Professional | | $2,206.13 | $3,470.45 | $5,286.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.67 / $2,224.98 / $3,653.51
| Facility | | $1,444.67 | $2,224.98 | $3,653.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.01 / $2,638.44 / $5,605.35
| Professional | | $1,530.01 | $2,638.44 | $5,605.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,720.00 / $3,500.00 / $8,152.00
| Facility | | $1,720.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.01 / $2,679.31 / $5,356.50
| Professional | | $1,530.01 | $2,679.31 | $5,356.50 |