- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,348.96 / $10,232.93
| Professional | | $1,096.48 | $1,348.96 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,949.84 / $1,995.26
| Professional | | $1,778.28 | $1,949.84 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,290.87
| Facility | | $1,318.26 | $1,318.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,570.40 / $3,801.89
| Professional | | $1,318.26 | $2,570.40 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,290.87 / $10,471.29
| Facility | | $1,288.25 | $2,290.87 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $2,089.30
| Professional | | $676.08 | $1,000.00 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $5,011.87
| Professional | | $2,238.72 | $2,238.72 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,011.87 / $5,011.87
| Professional | | $2,818.38 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,174.90 / $2,290.87
| Facility | | $776.25 | $1,174.90 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $1,584.89
| Professional | | $676.08 | $1,000.00 | $1,584.89 |