- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,290.87 / $2,290.87
| Facility | | $1,548.82 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $5,011.87
| Professional | | $1,445.44 | $1,819.70 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $12,302.69
| Facility | | $3,467.37 | $3,467.37 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $3,235.94
| Professional | | $1,819.70 | $1,819.70 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $3,467.37
| Professional | | $2,089.30 | $2,089.30 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $2,238.72
| Facility | | $1,548.82 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,238.72
| Professional | | $1,621.81 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $7,585.78
| Facility | | $1,698.24 | $2,754.23 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,737.80 / $17,378.01
| Professional | | $1,202.26 | $1,737.80 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $3,235.94
| Facility | | $2,041.74 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,398.83
| Professional | | $1,202.26 | $1,698.24 | $2,398.83 |