- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,096.48 / $1,096.48
| Facility | | $1,023.29 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $363.08 / $371.54
| Professional | | $354.81 | $363.08 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $501.19
| Professional | | $416.87 | $416.87 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,096.48
| Facility | | $1,023.29 | $1,023.29 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $371.54 / $426.58
| Professional | | $354.81 | $371.54 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $371.54 / $588.84
| Professional | | $75.86 | $371.54 | $588.84 |