- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,621.81 / $2,137.96
| Facility | | $1,047.13 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,023.29 / $1,202.26
| Professional | | $851.14 | $1,023.29 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $891.25 / $2,398.83
| Facility | | $147.91 | $891.25 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $1,047.13 / $1,318.26
| Professional | | $147.91 | $1,047.13 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $2,290.87
| Facility | | $1,174.90 | $1,174.90 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $891.25
| Professional | | $407.38 | $407.38 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $891.25 / $2,398.83
| Facility | | $147.91 | $891.25 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $1,047.13 / $1,318.26
| Professional | | $147.91 | $1,047.13 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,318.26 / $1,698.24
| Facility | | $794.33 | $1,318.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,047.13 / $1,412.54
| Professional | | $407.38 | $1,047.13 | $1,412.54 |