- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.93 / $1,162.93 / $1,535.63
| Facility | | $1,162.93 | $1,162.93 | $1,535.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.48 / $595.48 / $595.48
| Professional | | $595.48 | $595.48 | $595.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $560.45 / $700.56 / $1,050.83
| Facility | | $560.45 | $700.56 | $1,050.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.36 / $455.36 / $700.56
| Professional | | $455.36 | $455.36 | $700.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.56 / $1,071.85 / $1,341.57
| Professional | | $700.56 | $1,071.85 | $1,341.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.67 / $840.67 / $840.67
| Facility | | $840.67 | $840.67 | $840.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.28 / $420.34 / $721.58
| Professional | | $350.28 | $420.34 | $721.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,218.97 / $3,327.66 / $3,327.66
| Facility | | $1,218.97 | $3,327.66 | $3,327.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,488.79 / $3,488.79 / $5,254.20
| Professional | | $3,488.79 | $3,488.79 | $5,254.20 |