- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.37 / $1,487.37 / $3,718.43
| Facility | | $1,487.37 | $1,487.37 | $3,718.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.77 / $1,204.77 / $1,487.37
| Professional | | $1,204.77 | $1,204.77 | $1,487.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.17 / $1,487.37 / $5,141.84
| Facility | | $407.17 | $1,487.37 | $5,141.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.73 / $594.95 / $966.79
| Professional | | $64.73 | $594.95 | $966.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,172.52 / $3,172.52 / $3,172.52
| Facility | | $3,172.52 | $3,172.52 | $3,172.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.14 / $1,708.99 / $2,136.23
| Professional | | $1,505.14 | $1,708.99 | $2,136.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.37 / $1,487.37 / $1,801.21
| Professional | | $1,487.37 | $1,487.37 | $1,801.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.37 / $1,487.37 / $3,718.43
| Facility | | $1,487.37 | $1,487.37 | $3,718.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.77 / $1,204.77 / $1,487.37
| Professional | | $1,204.77 | $1,204.77 | $1,487.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.42 / $892.42 / $2,156.69
| Professional | | $892.42 | $892.42 | $2,156.69 |