- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,158.59 / $1,158.59 / $1,158.59
| Facility | | $1,158.59 | $1,158.59 | $1,158.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.54 / $759.08 / $1,158.59
| Professional | | $404.54 | $759.08 | $1,158.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,003.79 / $1,095.18 / $1,161.64
| Facility | | $1,003.79 | $1,095.18 | $1,161.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.05 / $1,087.05 / $1,087.05
| Professional | | $1,087.05 | $1,087.05 | $1,087.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $907.46 / $907.46 / $907.46
| Facility | | $907.46 | $907.46 | $907.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.45 / $907.46 / $2,037.66
| Professional | | $662.45 | $907.46 | $2,037.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.54 / $1,127.58 / $6,547.41
| Facility | | $404.54 | $1,127.58 | $6,547.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.75 / $698.01 / $1,339.78
| Professional | | $417.75 | $698.01 | $1,339.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.75 / $695.67 / $934.86
| Professional | | $417.75 | $695.67 | $934.86 |