- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $2,187.76
| Facility | | $1,202.26 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $1,513.56
| Professional | | $851.14 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $891.25 / $891.25
| Professional | | $851.14 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,905.46
| Professional | | $1,548.82 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $3,019.95
| Facility | | $1,202.26 | $1,202.26 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $1,698.24
| Professional | | $1,047.13 | $1,258.93 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,258.93 / $1,513.56
| Facility | | $1,148.15 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $758.58 / $1,258.93
| Professional | | $524.81 | $758.58 | $1,258.93 |