- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,047.56 / $2,047.56 / $2,047.56
| Facility | | $2,047.56 | $2,047.56 | $2,047.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.92 / $2,047.56 / $3,076.19
| Professional | | $1,284.92 | $2,047.56 | $3,076.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,095.11 / $4,601.27 / $8,354.02
| Facility | | $4,095.11 | $4,601.27 | $8,354.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.84 / $2,207.84 / $2,384.46
| Professional | | $2,207.84 | $2,207.84 | $2,384.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $2,282.71 / $2,282.71
| Facility | | $2,282.71 | $2,282.71 | $2,282.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $4,710.75
| Professional | | $1,666.39 | $1,666.39 | $4,710.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,176.59 / $2,047.56 / $5,118.89
| Facility | | $1,176.59 | $2,047.56 | $5,118.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.59 / $1,176.59 / $1,176.59
| Professional | | $1,176.59 | $1,176.59 | $1,176.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,989.43 / $5,118.89 / $8,108.32
| Professional | | $2,989.43 | $5,118.89 | $8,108.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,685.08 / $1,822.54 / $2,808.47
| Professional | | $1,685.08 | $1,822.54 | $2,808.47 |