- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.81 / $1,470.81 / $1,470.81
| Facility | | $1,470.81 | $1,470.81 | $1,470.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.02 / $1,470.81 / $1,959.98
| Professional | | $1,059.02 | $1,470.81 | $1,959.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,626.45 / $2,951.08 / $5,357.96
| Facility | | $2,626.45 | $2,951.08 | $5,357.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.13 / $1,482.13 / $1,482.13
| Professional | | $1,482.13 | $1,482.13 | $1,482.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.80 / $1,638.80 / $1,638.80
| Facility | | $1,638.80 | $1,638.80 | $1,638.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.32 / $1,196.32 / $2,937.00
| Professional | | $1,196.32 | $1,196.32 | $2,937.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $783.77 / $1,470.81 / $3,304.20
| Facility | | $783.77 | $1,470.81 | $3,304.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.77 / $783.77 / $783.77
| Professional | | $783.77 | $783.77 | $783.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.31 / $3,283.06 / $5,200.37
| Professional | | $1,917.31 | $3,283.06 | $5,200.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,203.23 / $1,203.23 / $1,416.40
| Facility | | $1,203.23 | $1,203.23 | $1,416.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.34 / $1,214.06 / $1,828.81
| Professional | | $1,102.34 | $1,214.06 | $1,828.81 |