- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,355.39 / $1,355.39 / $2,003.62
| Facility | | $1,355.39 | $1,355.39 | $2,003.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.39 / $1,882.82 / $2,003.62
| Professional | | $1,355.39 | $1,882.82 | $2,003.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.40 / $1,481.67 / $2,279.06
| Professional | | $1,329.40 | $1,481.67 | $2,279.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $278.61 / $495.31 / $4,780.88
| Facility | | $278.61 | $495.31 | $4,780.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.57 / $510.79 / $6,059.83
| Professional | | $309.57 | $510.79 | $6,059.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $3,117.54
| Facility | | $1,406.76 | $1,406.76 | $3,117.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.75 / $1,406.76 / $2,791.23
| Professional | | $1,195.75 | $1,406.76 | $2,791.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.38 / $270.81 / $2,708.16
| Professional | | $190.38 | $270.81 | $2,708.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.16 / $1,302.91 / $1,883.37
| Professional | | $759.16 | $1,302.91 | $1,883.37 |