- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,338.02 / $1,338.02 / $1,338.02
| Facility | | $1,338.02 | $1,338.02 | $1,338.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.47 / $1,256.68 / $1,338.02
| Professional | | $737.47 | $1,256.68 | $1,338.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,376.79 / $1,705.06 / $2,246.06
| Facility | | $1,376.79 | $1,705.06 | $2,246.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.96 / $1,549.53 / $1,597.45
| Professional | | $1,277.96 | $1,549.53 | $1,597.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.71 / $4,928.60 / $13,688.76
| Facility | | $891.71 | $4,928.60 | $13,688.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.75 / $1,962.86 / $2,351.71
| Professional | | $1,851.75 | $1,962.86 | $2,351.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,926.05 / $4,728.75 / $10,778.55
| Facility | | $2,926.05 | $4,728.75 | $10,778.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.75 / $1,851.75 / $1,905.60
| Professional | | $1,851.75 | $1,851.75 | $1,905.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.08 / $1,597.45 / $7,438.91
| Facility | | $497.08 | $1,597.45 | $7,438.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.63 / $796.19 / $1,604.13
| Professional | | $474.63 | $796.19 | $1,604.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.45 / $860.44 / $2,805.92
| Professional | | $557.45 | $860.44 | $2,805.92 |