- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,041.74 / $4,570.88
| Facility | | $891.25 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $1,905.46
| Professional | | $870.96 | $1,071.52 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,311.31 / $9,332.54
| Facility | | $1,659.59 | $3,311.31 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $1,584.89
| Professional | | $1,047.13 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $870.96
| Facility | | $39.81 | $39.81 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Facility | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,380.38 / $1,905.46
| Professional | | $812.83 | $1,380.38 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,398.83 / $5,888.44
| Facility | | $831.76 | $2,398.83 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,122.02 / $1,862.09
| Professional | | $870.96 | $1,122.02 | $1,862.09 |