- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.03 / $1,370.03 / $1,467.58
| Facility | | $1,370.03 | $1,370.03 | $1,467.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.03 / $1,370.03 / $1,370.03
| Professional | | $1,370.03 | $1,370.03 | $1,370.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.96 / $24.74 / $48.24
| Facility | | $18.96 | $24.74 | $48.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.60 / $3,155.21 / $3,383.55
| Professional | | $1,577.60 | $3,155.21 | $3,383.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $3,769.92 / $4,712.39
| Professional | | $2,385.08 | $3,769.92 | $4,712.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.48 / $2,466.05 / $9,860.04
| Facility | | $1,245.48 | $2,466.05 | $9,860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.48 / $1,245.48 / $4,151.60
| Professional | | $1,245.48 | $1,245.48 | $4,151.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,490.96 / $4,276.14 / $5,709.37
| Facility | | $2,490.96 | $4,276.14 | $5,709.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,490.96 / $4,276.14 / $5,709.37
| Professional | | $2,490.96 | $4,276.14 | $5,709.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.21 / $1,245.48 / $4,151.60
| Professional | | $1,183.21 | $1,245.48 | $4,151.60 |