- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,162.28 / $5,011.87
| Facility | | $1,778.28 | $3,162.28 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $398.11 / $1,348.96
| Professional | | $331.13 | $398.11 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $1,949.84
| Facility | | $407.38 | $407.38 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $1,318.26
| Professional | | $407.38 | $407.38 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $1,513.56 / $1,621.81
| Facility | | $407.38 | $1,513.56 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $1,122.02 / $1,949.84
| Facility | | $323.59 | $1,122.02 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $812.83 / $1,230.27
| Professional | | $245.47 | $812.83 | $1,230.27 |