- 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
- $1,047.13 / $1,412.54 / $2,290.87
| Professional | | $1,047.13 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,235.94 / $6,309.57
| Facility | | $2,884.03 | $3,235.94 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,862.09
| Professional | | $1,412.54 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,862.09
| Professional | | $1,318.26 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,884.03 / $5,370.32
| Professional | | $1,737.80 | $2,884.03 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,884.03 / $2,884.03
| Professional | | $2,691.53 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $1,778.28
| Facility | | $1,047.13 | $1,548.82 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $1,778.28
| Professional | | $1,047.13 | $1,174.90 | $1,778.28 |