- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $2,187.76
| Facility | | $1,479.11 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,548.82 / $1,548.82
| Professional | | $933.25 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,288.25 / $2,570.40
| Facility | | $645.65 | $1,288.25 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $537.03 / $537.03
| Professional | | $524.81 | $537.03 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $2,570.40
| Facility | | $1,479.11 | $2,041.74 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,548.82 / $1,949.84
| Professional | | $724.44 | $1,548.82 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,479.11 / $1,949.84
| Facility | | $831.76 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Professional | | $478.63 | $478.63 | $478.63 |