- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,763.19 / $1,896.26 / $2,172.54
| Facility | | $1,763.19 | $1,896.26 | $2,172.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.19 / $2,172.54 / $3,073.84
| Professional | | $1,763.19 | $2,172.54 | $3,073.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,097.42 / $3,097.42 / $3,716.90
| Professional | | $3,097.42 | $3,097.42 | $3,716.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.04 / $2,550.04 / $2,550.04
| Facility | | $2,550.04 | $2,550.04 | $2,550.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $1,861.53 / $2,907.84
| Professional | | $1,861.53 | $1,861.53 | $2,907.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,430.52 / $2,991.02 / $2,991.02
| Facility | | $1,430.52 | $2,991.02 | $2,991.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.38 / $2,981.27 / $4,129.89
| Professional | | $1,968.38 | $2,981.27 | $4,129.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.39 / $2,192.92 / $2,412.21
| Professional | | $1,425.39 | $2,192.92 | $2,412.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,441.30 / $5,441.30 / $5,441.30
| Facility | | $5,441.30 | $5,441.30 | $5,441.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.50 / $2,060.36 / $3,067.56
| Professional | | $1,773.50 | $2,060.36 | $3,067.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,192.92 / $2,192.92 / $2,469.42
| Professional | | $2,192.92 | $2,192.92 | $2,469.42 |