- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,479.11
| Facility | | $1,096.48 | $1,096.48 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,548.82
| Professional | | $794.33 | $1,047.13 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $3,981.07
| Facility | | $1,698.24 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,862.09
| Professional | | $870.96 | $870.96 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,548.82 / $2,630.27
| Facility | | $724.44 | $1,548.82 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $1,380.38
| Professional | | $645.65 | $912.01 | $1,380.38 |