- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $9,120.11
| Facility | | $1,318.26 | $1,905.46 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,041.74
| Professional | | $1,778.28 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $2,041.74
| Facility | | $812.83 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,778.28
| Facility | | $1,659.59 | $1,659.59 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,778.28 / $1,778.28
| Professional | | $549.54 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $3,090.30
| Facility | | $1,258.93 | $1,737.80 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,737.80 / $1,949.84
| Professional | | $1,548.82 | $1,737.80 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,778.28 / $1,778.28
| Facility | | $1,737.80 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $1,949.84
| Professional | | $1,659.59 | $1,778.28 | $1,949.84 |