- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,143.80 / $2,066.21 / $3,228.47
| Facility | | $1,143.80 | $2,066.21 | $3,228.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.74 / $2,066.21 / $3,182.35
| Professional | | $1,881.74 | $2,066.21 | $3,182.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.67 / $760.67 / $760.67
| Facility | | $760.67 | $760.67 | $760.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,319.06 / $1,319.06 / $1,319.06
| Facility | | $1,319.06 | $1,319.06 | $1,319.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.35 / $275.35 / $886.63
| Professional | | $275.35 | $275.35 | $886.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $963.73 / $1,018.80 / $1,101.40
| Facility | | $963.73 | $1,018.80 | $1,101.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.82 / $619.54 / $619.54
| Professional | | $247.82 | $619.54 | $619.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.67 / $1,018.80 / $1,319.06
| Facility | | $760.67 | $1,018.80 | $1,319.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.21 / $757.21 / $757.21
| Professional | | $757.21 | $757.21 | $757.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.35 / $550.70 / $830.79
| Professional | | $275.35 | $550.70 | $830.79 |