- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $2,398.83
| Facility | | $1,000.00 | $1,230.27 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $933.25
| Professional | | $691.83 | $691.83 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,096.48 / $2,511.89
| Facility | | $363.08 | $1,096.48 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $758.58 / $1,202.26
| Professional | | $575.44 | $758.58 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Professional | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $758.58 / $1,288.25
| Facility | | $691.83 | $758.58 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $2,818.38
| Professional | | $691.83 | $691.83 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $691.83 / $1,047.13
| Facility | | $645.65 | $691.83 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $691.83 / $758.58
| Professional | | $645.65 | $691.83 | $758.58 |