- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,949.84 / $2,570.40
| Facility | | $1,258.93 | $1,949.84 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,258.93 / $1,258.93
| Professional | | $1,174.90 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,235.94 / $6,606.93
| Facility | | $1,318.26 | $3,235.94 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,318.26 / $1,348.96
| Professional | | $1,288.25 | $1,318.26 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,348.96 / $1,659.59
| Professional | | $1,258.93 | $1,348.96 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,235.94 / $6,606.93
| Facility | | $1,318.26 | $3,235.94 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,318.26 / $1,348.96
| Professional | | $1,288.25 | $1,318.26 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.26 / $512.86 / $1,202.26
| Facility | | $1.26 | $512.86 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $1,288.25
| Professional | | $1,071.52 | $1,288.25 | $1,288.25 |