- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,777.51 / $1,777.51 / $1,777.51
| Facility | | $1,777.51 | $1,777.51 | $1,777.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.36 / $1,237.51 / $1,980.01
| Professional | | $672.36 | $1,237.51 | $1,980.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,707.60 / $1,863.08 / $1,976.16
| Facility | | $1,707.60 | $1,863.08 | $1,976.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.26 / $1,849.26 / $1,849.26
| Professional | | $1,849.26 | $1,849.26 | $1,849.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.00 / $1,620.00 / $1,620.00
| Facility | | $1,620.00 | $1,620.00 | $1,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.59 / $1,620.00 / $3,629.06
| Professional | | $1,182.59 | $1,620.00 | $3,629.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $672.36 / $1,905.13 / $11,250.63
| Facility | | $672.36 | $1,905.13 | $11,250.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.32 / $1,353.53 / $3,020.07
| Professional | | $694.32 | $1,353.53 | $3,020.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,365.94 / $2,365.94 / $2,783.46
| Facility | | $2,365.94 | $2,365.94 | $2,783.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.22 / $1,179.33 / $1,604.89
| Professional | | $786.22 | $1,179.33 | $1,604.89 |