- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,454.71 / $2,454.71
| Facility | | $1,412.54 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $2,290.87
| Professional | | $1,096.48 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,235.94 / $6,165.95
| Facility | | $2,884.03 | $3,235.94 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $1,905.46
| Professional | | $1,412.54 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Facility | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,584.89
| Professional | | $1,096.48 | $1,096.48 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,884.03 / $5,623.41
| Professional | | $1,737.80 | $2,884.03 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $2,884.03
| Professional | | $2,754.23 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,584.89 / $1,819.70
| Facility | | $1,071.52 | $1,584.89 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,174.90 / $1,819.70
| Professional | | $1,071.52 | $1,174.90 | $1,819.70 |