- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,163.92 / $1,163.92 / $1,163.92
| Facility | | $1,163.92 | $1,163.92 | $1,163.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.92 / $1,163.92 / $1,511.36
| Professional | | $1,163.92 | $1,163.92 | $1,511.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.11 / $1,764.54 / $1,782.35
| Professional | | $1,604.11 | $1,764.54 | $1,782.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.53 / $2,007.65 / $2,007.65
| Facility | | $1,395.53 | $2,007.65 | $2,007.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.95 / $2,345.21 / $3,126.09
| Professional | | $1,952.95 | $2,345.21 | $3,126.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.81 / $2,001.77 / $9,370.62
| Facility | | $1,080.81 | $2,001.77 | $9,370.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.62 / $910.54 / $1,517.56
| Professional | | $685.62 | $910.54 | $1,517.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,001.77 / $2,007.65 / $2,709.67
| Facility | | $2,001.77 | $2,007.65 | $2,709.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.00 / $2,372.67 / $4,136.06
| Professional | | $1,815.00 | $2,372.67 | $4,136.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.62 / $910.54 / $1,371.23
| Professional | | $685.62 | $910.54 | $1,371.23 |