- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,692.46 / $3,057.35 / $4,777.12
| Facility | | $1,692.46 | $3,057.35 | $4,777.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $3,057.35 / $4,708.87
| Professional | | $2,784.38 | $3,057.35 | $4,708.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.53 / $1,125.53 / $1,125.53
| Facility | | $1,125.53 | $1,125.53 | $1,125.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.79 / $1,951.79 / $1,951.79
| Facility | | $1,951.79 | $1,951.79 | $1,951.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.96 / $1,222.29 / $1,311.92
| Professional | | $148.96 | $1,222.29 | $1,311.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,426.01 / $1,507.49 / $1,629.72
| Facility | | $1,426.01 | $1,507.49 | $1,629.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.69 / $916.72 / $916.72
| Professional | | $366.69 | $916.72 | $916.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.53 / $1,507.49 / $1,951.79
| Facility | | $1,125.53 | $1,507.49 | $1,951.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.96 / $1,120.43 / $1,120.43
| Professional | | $148.96 | $1,120.43 | $1,120.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.51 / $331.02 / $499.38
| Professional | | $165.51 | $331.02 | $499.38 |