- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.46 / $1,412.46 / $1,412.46
| Facility | | $1,412.46 | $1,412.46 | $1,412.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.39 / $1,412.46 / $1,621.71
| Professional | | $844.39 | $1,412.46 | $1,621.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,752.03 / $2,169.76 / $2,858.21
| Facility | | $1,752.03 | $2,169.76 | $2,858.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.26 / $1,931.19 / $2,032.83
| Professional | | $1,626.26 | $1,931.19 | $2,032.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.41 / $6,272.48 / $17,421.27
| Facility | | $1,108.41 | $6,272.48 | $17,421.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,356.50 / $2,497.89 / $2,992.76
| Professional | | $2,356.50 | $2,497.89 | $2,992.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,723.89 / $6,018.13 / $13,717.54
| Facility | | $3,723.89 | $6,018.13 | $13,717.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,356.50 / $2,356.50 / $2,425.19
| Professional | | $2,356.50 | $2,356.50 | $2,425.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $579.54 / $2,032.83 / $9,247.12
| Facility | | $579.54 | $2,032.83 | $9,247.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.04 / $973.26 / $2,132.62
| Professional | | $581.04 | $973.26 | $2,132.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.04 / $971.82 / $2,041.33
| Professional | | $581.04 | $971.82 | $2,041.33 |