- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,339.78 / $1,339.78 / $1,339.78
| Facility | | $1,339.78 | $1,339.78 | $1,339.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.52 / $1,339.78 / $2,531.16
| Professional | | $1,157.52 | $1,339.78 | $2,531.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,679.56 / $3,010.75 / $5,466.30
| Facility | | $2,679.56 | $3,010.75 | $5,466.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,619.41 / $1,619.41 / $1,748.96
| Professional | | $1,619.41 | $1,619.41 | $1,748.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $1,667.14 / $3,417.49
| Professional | | $1,667.14 | $1,667.14 | $3,417.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $863.01 / $1,339.78 / $3,738.95
| Facility | | $863.01 | $1,339.78 | $3,738.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.01 / $863.01 / $863.01
| Professional | | $863.01 | $863.01 | $863.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.08 / $3,349.45 / $5,305.53
| Professional | | $1,956.08 | $3,349.45 | $5,305.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.98 / $1,336.80 / $2,059.96
| Professional | | $1,235.98 | $1,336.80 | $2,059.96 |