- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,050.81 / $1,050.81 / $1,050.81
| Facility | | $1,050.81 | $1,050.81 | $1,050.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.40 / $1,050.81 / $1,413.05
| Professional | | $854.40 | $1,050.81 | $1,413.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,876.44 / $2,108.37 / $3,827.94
| Facility | | $1,876.44 | $2,108.37 | $3,827.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.53 / $1,130.53 / $1,220.97
| Professional | | $1,130.53 | $1,130.53 | $1,220.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,172.51 / $1,172.51
| Facility | | $1,172.51 | $1,172.51 | $1,172.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.93 / $855.93 / $2,007.85
| Professional | | $855.93 | $855.93 | $2,007.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.35 / $1,050.81 / $2,360.66
| Facility | | $604.35 | $1,050.81 | $2,360.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.35 / $604.35 / $604.35
| Professional | | $604.35 | $604.35 | $604.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.80 / $2,345.55 / $3,715.35
| Professional | | $1,369.80 | $2,345.55 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.01 / $936.14 / $1,410.16
| Professional | | $850.01 | $936.14 | $1,410.16 |