- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,130.97 / $1,130.97 / $1,671.88
| Facility | | $1,130.97 | $1,130.97 | $1,671.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.90 / $1,387.41 / $1,671.88
| Professional | | $784.90 | $1,387.41 | $1,671.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,552.28 / $1,552.28 / $1,552.28
| Professional | | $1,552.28 | $1,552.28 | $1,552.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.20 / $1,236.28 / $1,901.61
| Professional | | $1,109.20 | $1,236.28 | $1,901.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.27 / $1,937.26 / $3,745.50
| Facility | | $258.27 | $1,937.26 | $3,745.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.36 / $2,615.30 / $4,707.14
| Professional | | $276.36 | $2,615.30 | $4,707.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $3,027.07
| Facility | | $1,460.50 | $1,460.50 | $3,027.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $2,135.32
| Professional | | $1,241.43 | $1,460.50 | $2,135.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.78 / $264.86 / $2,648.68
| Professional | | $211.78 | $264.86 | $2,648.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.12 / $1,277.18 / $1,650.02
| Professional | | $859.12 | $1,277.18 | $1,650.02 |