- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,658.58 / $1,658.58 / $1,658.58
| Facility | | $1,658.58 | $1,658.58 | $1,658.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.81 / $1,658.58 / $1,658.58
| Professional | | $1,051.81 | $1,658.58 | $1,658.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,044.83 / $2,387.05 / $3,323.88
| Facility | | $2,044.83 | $2,387.05 | $3,323.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,909.64 / $2,267.69 / $2,387.05
| Professional | | $1,909.64 | $2,267.69 | $2,387.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $7,364.96 / $20,455.56
| Facility | | $1,544.16 | $7,364.96 | $20,455.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,767.50 / $2,933.55 / $3,514.73
| Professional | | $2,767.50 | $2,933.55 | $3,514.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,372.49 / $7,066.32 / $16,106.74
| Facility | | $4,372.49 | $7,066.32 | $16,106.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,767.50 / $2,767.50 / $2,847.60
| Professional | | $2,767.50 | $2,767.50 | $2,847.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $668.10 / $2,387.05 / $10,889.05
| Facility | | $668.10 | $2,387.05 | $10,889.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.82 / $1,115.45 / $2,397.02
| Professional | | $669.82 | $1,115.45 | $2,397.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.82 / $1,115.45 / $2,699.75
| Professional | | $669.82 | $1,115.45 | $2,699.75 |