- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,754.23 / $5,495.41
| Facility | | $1,659.59 | $2,754.23 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,288.25 / $1,513.56
| Professional | | $1,258.93 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,288.25 / $4,677.35
| Facility | | $354.81 | $1,288.25 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,238.72
| Professional | | $1,096.48 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $354.81 / $562.34
| Facility | | $158.49 | $354.81 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,584.89
| Professional | | $1,288.25 | $1,288.25 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $1,288.25 / $1,380.38
| Professional | | $346.74 | $1,288.25 | $1,380.38 |