- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,187.72 / $1,187.72 / $1,187.72
| Facility | | $1,187.72 | $1,187.72 | $1,187.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.57 / $985.55 / $1,187.72
| Professional | | $846.57 | $985.55 | $1,187.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.62 / $2,294.59 / $2,868.24
| Professional | | $1,814.62 | $2,294.59 | $2,868.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,192.52 / $1,430.70 / $2,319.60
| Facility | | $1,192.52 | $1,430.70 | $2,319.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.40 / $758.12 / $2,486.63
| Professional | | $644.40 | $758.12 | $2,486.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.24 / $2,211.17 / $3,396.88
| Facility | | $1,516.24 | $2,211.17 | $3,396.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.24 / $2,486.63 / $3,396.88
| Professional | | $1,516.24 | $2,486.63 | $3,396.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.85 / $3,044.22 / $3,471.17
| Professional | | $1,806.85 | $3,044.22 | $3,471.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $758.12 / $1,667.86
| Professional | | $530.67 | $758.12 | $1,667.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $1,263.53
| Professional | | $1,263.53 | $1,263.53 | $1,263.53 |