- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.33 / $1,210.33 / $1,210.33
| Facility | | $1,210.33 | $1,210.33 | $1,210.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.66 / $1,210.33 / $1,486.96
| Professional | | $1,068.66 | $1,210.33 | $1,486.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,009.30 / $1,981.58 / $3,865.42
| Facility | | $1,009.30 | $1,981.58 | $3,865.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.14 / $1,817.68 / $1,817.68
| Professional | | $1,454.14 | $1,817.68 | $1,817.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,835.06 / $4,020.47 / $9,671.78
| Facility | | $2,835.06 | $4,020.47 | $9,671.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.48 / $3,147.81 / $4,901.78
| Professional | | $2,059.48 | $3,147.81 | $4,901.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,576.00 / $3,675.67 / $7,615.58
| Facility | | $2,576.00 | $3,675.67 | $7,615.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,935.52 / $2,896.63 / $4,429.10
| Professional | | $1,935.52 | $2,896.63 | $4,429.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,177.58 / $1,928.62 / $3,030.69
| Facility | | $1,177.58 | $1,928.62 | $3,030.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.64 / $2,291.46 / $4,564.10
| Professional | | $1,280.64 | $2,291.46 | $4,564.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.31 / $2,109.78 / $3,993.11
| Professional | | $1,289.31 | $2,109.78 | $3,993.11 |