- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $1,548.82
| Facility | | $1,047.13 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $3,388.44
| Professional | | $1,047.13 | $1,348.96 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $8,317.64
| Facility | | $2,344.23 | $2,344.23 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,380.38 / $2,187.76
| Professional | | $1,348.96 | $1,380.38 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $2,344.23
| Professional | | $1,412.54 | $1,412.54 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,737.80 / $1,737.80
| Facility | | $1,047.13 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,737.80
| Professional | | $1,288.25 | $1,288.25 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,949.84 / $5,495.41
| Facility | | $1,202.26 | $1,949.84 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $12,882.50
| Professional | | $870.96 | $1,230.27 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,862.09 / $1,862.09
| Facility | | $1,479.11 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,148.15 / $1,698.24
| Professional | | $870.96 | $1,148.15 | $1,698.24 |