- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,659.59 / $2,454.71
| Facility | | $1,071.52 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $977.24 / $1,584.89
| Professional | | $389.05 | $977.24 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,479.11 / $1,659.59
| Professional | | $851.14 | $1,479.11 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $4,570.88
| Facility | | $3,311.31 | $3,311.31 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,230.27
| Professional | | $933.25 | $933.25 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,096.48 / $1,621.81
| Professional | | $630.96 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,698.24 / $1,905.46
| Professional | | $977.24 | $1,698.24 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $10,000.00
| Facility | | $1,230.27 | $2,951.21 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $1,659.59
| Professional | | $933.25 | $1,174.90 | $1,659.59 |