- 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
- $1,047.13 / $1,288.25 / $9,332.54
| Professional | | $1,047.13 | $1,288.25 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,949.84 / $1,949.84
| Professional | | $1,778.28 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $2,290.87
| Facility | | $1,584.89 | $1,584.89 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,691.53 / $3,630.78
| Professional | | $1,584.89 | $2,691.53 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,238.72 / $9,772.37
| Facility | | $1,288.25 | $2,238.72 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,230.27 / $2,041.74
| Professional | | $676.08 | $1,230.27 | $2,041.74 |
- 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
- $851.14 / $1,412.54 / $2,187.76
| Facility | | $851.14 | $1,412.54 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,513.56
| Professional | | $776.25 | $1,000.00 | $1,513.56 |