- 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
- $575.44 / $776.25 / $1,122.02
| Professional | | $575.44 | $776.25 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,513.56 / $2,187.76
| Facility | | $1,479.11 | $1,513.56 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $1,513.56
| Professional | | $1,202.26 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,623.41 / $13,489.63
| Facility | | $3,162.28 | $5,623.41 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,995.26 / $2,187.76
| Professional | | $1,737.80 | $1,995.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,623.41 / $10,471.29
| Facility | | $4,365.16 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,344.23
| Professional | | $1,737.80 | $1,737.80 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,513.56 / $3,090.30
| Facility | | $630.96 | $1,513.56 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $1,548.82
| Professional | | $426.58 | $630.96 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.23 / $630.96 / $1,737.80
| Facility | | $10.23 | $630.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $707.95 / $1,862.09
| Professional | | $489.78 | $707.95 | $1,862.09 |