- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,951.21 / $2,951.21
| Facility | | $1,698.24 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,862.09 / $2,951.21
| Professional | | $1,513.56 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,890.45 / $7,413.10
| Facility | | $3,467.37 | $3,890.45 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,570.40
| Professional | | $1,949.84 | $1,949.84 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,951.21
| Professional | | $2,454.71 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,467.37 / $8,128.31
| Professional | | $2,089.30 | $3,467.37 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,467.37 / $3,467.37
| Professional | | $3,388.44 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.57 / $1,995.26 / $2,454.71
| Facility | | $2.57 | $1,995.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,621.81 / $2,398.83
| Professional | | $1,445.44 | $1,621.81 | $2,398.83 |