- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.55 / $2,189.89 / $2,841.89
| Facility | | $1,028.55 | $2,189.89 | $2,841.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.55 / $1,041.41 / $1,726.11
| Professional | | $1,028.55 | $1,041.41 | $1,726.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.85 / $1,285.72 / $1,285.72
| Facility | | $1,092.85 | $1,285.72 | $1,285.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.43 / $1,285.72 / $1,285.72
| Professional | | $1,221.43 | $1,285.72 | $1,285.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.42 / $1,092.83 / $1,545.55
| Professional | | $531.42 | $1,092.83 | $1,545.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.83 / $1,316.54 / $1,954.25
| Facility | | $523.83 | $1,316.54 | $1,954.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.74 / $1,071.41 / $4,885.62
| Professional | | $1,007.74 | $1,071.41 | $4,885.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.87 / $531.42 / $1,584.19
| Facility | | $508.87 | $531.42 | $1,584.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.11 / $1,007.74 / $1,591.88
| Professional | | $384.11 | $1,007.74 | $1,591.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.40 / $596.40 / $764.60
| Professional | | $596.40 | $596.40 | $764.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.41 / $1,071.41 / $1,274.98
| Professional | | $1,071.41 | $1,071.41 | $1,274.98 |