- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,297.82 / $1,297.82 / $1,729.03
| Facility | | $1,297.82 | $1,297.82 | $1,729.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.82 / $1,345.02 / $2,052.92
| Professional | | $1,297.82 | $1,345.02 | $2,052.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.13 / $2,603.09 / $11,443.66
| Facility | | $2,479.13 | $2,603.09 | $11,443.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.98 / $1,482.13 / $2,006.67
| Professional | | $1,252.98 | $1,482.13 | $2,006.67 |
- 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 / $1,196.32
| Professional | | $1,196.32 | $1,196.32 | $1,196.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,297.82 / $2,006.64 / $12,562.85
| Facility | | $1,297.82 | $2,006.64 | $12,562.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.85 / $1,236.82 / $3,013.38
| Professional | | $1,005.85 | $1,236.82 | $3,013.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.85 / $1,315.23 / $2,479.13
| Facility | | $1,005.85 | $1,315.23 | $2,479.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.87 / $1,236.82 / $2,547.58
| Professional | | $943.87 | $1,236.82 | $2,547.58 |