- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,076.73 / $1,076.73 / $1,076.73
| Facility | | $1,076.73 | $1,076.73 | $1,076.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.17 / $1,076.73 / $1,153.16
| Professional | | $885.17 | $1,076.73 | $1,153.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,749.10 / $1,885.40 / $2,012.43
| Facility | | $1,749.10 | $1,885.40 | $2,012.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.23 / $1,751.54 / $1,885.40
| Professional | | $1,401.23 | $1,751.54 | $1,885.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.04 / $860.04 / $4,514.54
| Facility | | $860.04 | $860.04 | $4,514.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.25 / $2,102.06 / $2,643.19
| Professional | | $2,081.25 | $2,102.06 | $2,643.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,193.49 / $3,193.49 / $3,554.75
| Facility | | $3,193.49 | $3,193.49 | $3,554.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.25 / $2,081.25 / $2,081.25
| Professional | | $2,081.25 | $2,081.25 | $2,081.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.63 / $491.54 / $8,057.06
| Facility | | $152.63 | $491.54 | $8,057.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.81 / $804.43 / $1,641.96
| Professional | | $503.81 | $804.43 | $1,641.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.81 / $825.71 / $1,641.96
| Professional | | $503.81 | $825.71 | $1,641.96 |