- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.49 / $1,812.37 / $1,812.37
| Facility | | $1,591.49 | $1,812.37 | $1,812.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.27 / $1,160.94 / $1,828.78
| Professional | | $906.27 | $1,160.94 | $1,828.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $2,368.44
| Facility | | $1,207.83 | $1,207.83 | $2,368.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.83 / $2,508.38 / $3,135.47
| Professional | | $1,207.83 | $2,508.38 | $3,135.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.58 / $2,280.08 / $2,793.87
| Professional | | $2,055.58 | $2,280.08 | $2,793.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.10 / $2,799.08 / $10,094.70
| Facility | | $1,373.10 | $2,799.08 | $10,094.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.33 / $1,347.08 / $2,941.82
| Professional | | $1,029.33 | $1,347.08 | $2,941.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,361.54 / $2,368.44 / $2,936.47
| Facility | | $2,361.54 | $2,368.44 | $2,936.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.76 / $2,766.69 / $4,526.08
| Professional | | $1,939.76 | $2,766.69 | $4,526.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.55 / $1,055.55 / $1,055.55
| Facility | | $1,055.55 | $1,055.55 | $1,055.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.33 / $1,109.99 / $2,288.57
| Professional | | $1,029.33 | $1,109.99 | $2,288.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,110.08 / $2,110.08 / $2,110.08
| Facility | | $2,110.08 | $2,110.08 | $2,110.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.96 / $2,110.08 / $2,110.08
| Professional | | $1,666.96 | $2,110.08 | $2,110.08 |