- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.62 / $1,050.14 / $2,214.77
| Facility | | $1,015.62 | $1,050.14 | $2,214.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.03 / $1,015.62 / $1,040.08
| Professional | | $985.03 | $1,015.62 | $1,040.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.71 / $1,005.87 / $1,788.46
| Facility | | $411.71 | $1,005.87 | $1,788.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.57 / $1,015.62 / $1,040.08
| Professional | | $686.57 | $1,015.62 | $1,040.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,040.08
| Facility | | $1,040.08 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.08 / $1,040.08 / $1,040.08
| Professional | | $1,040.08 | $1,040.08 | $1,040.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.78 / $790.78 / $790.78
| Facility | | $790.78 | $790.78 | $790.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.70 / $1,019.70 / $1,125.75
| Professional | | $1,019.70 | $1,019.70 | $1,125.75 |