- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,023.29 / $1,819.70
| Professional | | $707.95 | $1,023.29 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $281.84 / $1,318.26
| Facility | | $169.82 | $281.84 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $1,202.26 / $1,949.84
| Professional | | $281.84 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $1,023.29 / $2,344.23
| Facility | | $128.82 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $478.63 / $1,621.81
| Professional | | $31.62 | $478.63 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,819.70 / $2,570.40
| Facility | | $1,174.90 | $1,819.70 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,023.29 / $1,819.70
| Professional | | $794.33 | $1,023.29 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $77.62 / $77.62
| Professional | | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $416.87 / $549.54
| Facility | | $309.03 | $416.87 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $2,344.23
| Professional | | $1,412.54 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $323.59 / $446.68
| Professional | | $245.47 | $323.59 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $426.58 / $1,737.80
| Professional | | $416.87 | $426.58 | $1,737.80 |