- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,220.72 / $1,220.72 / $1,758.56
| Facility | | $1,220.72 | $1,220.72 | $1,758.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.83 / $777.83 / $777.83
| Professional | | $777.83 | $777.83 | $777.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.57 / $1,406.85 / $2,637.84
| Facility | | $527.57 | $1,406.85 | $2,637.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $813.81 / $1,318.92 / $1,450.81
| Facility | | $813.81 | $1,318.92 | $1,450.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.37 / $676.37 / $811.64
| Professional | | $676.37 | $676.37 | $811.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $1,318.92
| Professional | | $30.00 | $30.00 | $1,318.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.56 / $1,352.74 / $2,434.92
| Facility | | $1,014.56 | $1,352.74 | $2,434.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.92 / $1,010.92 / $1,044.71
| Professional | | $1,010.92 | $1,010.92 | $1,044.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.08 / $284.08 / $777.83
| Professional | | $284.08 | $284.08 | $777.83 |