- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.19 / $1,350.19 / $3,375.47
| Facility | | $1,350.19 | $1,350.19 | $3,375.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.65 / $1,093.65 / $1,350.19
| Professional | | $1,093.65 | $1,093.65 | $1,350.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.58 / $1,640.08 / $4,667.60
| Facility | | $1,306.58 | $1,640.08 | $4,667.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.08 / $594.08 / $2,289.64
| Professional | | $540.08 | $594.08 | $2,289.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,879.91 / $2,879.91 / $2,879.91
| Facility | | $2,879.91 | $2,879.91 | $2,879.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.63 / $1,366.34 / $1,939.55
| Professional | | $1,212.63 | $1,366.34 | $1,939.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.19 / $1,350.19 / $1,363.69
| Professional | | $1,350.19 | $1,350.19 | $1,363.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.19 / $1,350.19 / $3,375.47
| Facility | | $1,350.19 | $1,350.19 | $3,375.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.65 / $1,350.19 / $1,350.19
| Professional | | $1,093.65 | $1,350.19 | $1,350.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.11 / $810.11 / $1,957.78
| Professional | | $810.11 | $810.11 | $1,957.78 |