- 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
- $1,230.27 / $1,445.44 / $2,454.71
| Professional | | $1,230.27 | $1,445.44 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $891.25 / $11,748.98
| Facility | | $380.19 | $891.25 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $5,248.07
| Professional | | $2,344.23 | $3,388.44 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $11,481.54
| Facility | | $3,467.37 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,981.07 / $5,888.44
| Professional | | $2,344.23 | $3,981.07 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $9,120.11
| Facility | | $3,715.35 | $4,677.35 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,311.31 / $5,248.07
| Professional | | $2,511.89 | $3,311.31 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,238.72 / $3,715.35
| Facility | | $1,445.44 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,511.89 / $7,413.10
| Professional | | $1,380.38 | $2,511.89 | $7,413.10 |
- 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
- $1,412.54 / $2,454.71 / $5,011.87
| Professional | | $1,412.54 | $2,454.71 | $5,011.87 |