- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,905.46 / $2,691.53
| Professional | | $1,737.80 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,398.83 / $2,398.83
| Facility | | $2,041.74 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $2,041.74 / $2,398.83
| Professional | | $281.84 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,737.80 / $1,995.26
| Facility | | $316.23 | $1,737.80 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $363.08 / $3,235.94
| Facility | | $204.17 | $363.08 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $363.08 / $3,235.94
| Professional | | $204.17 | $363.08 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $269.15 / $1,778.28
| Facility | | $128.82 | $269.15 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $2,137.96
| Professional | | $1,122.02 | $1,348.96 | $2,137.96 |