- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,477.74 / $1,477.74 / $1,477.74
| Facility | | $1,477.74 | $1,477.74 | $1,477.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.43 / $968.17 / $1,477.74
| Professional | | $459.43 | $968.17 | $1,477.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,229.16 / $1,341.07 / $1,422.45
| Facility | | $1,229.16 | $1,341.07 | $1,422.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.12 / $1,331.12 / $1,331.12
| Professional | | $1,331.12 | $1,331.12 | $1,331.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.35 / $891.35 / $891.35
| Facility | | $891.35 | $891.35 | $891.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.69 / $891.35 / $2,573.91
| Professional | | $650.69 | $891.35 | $2,573.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $459.43 / $1,438.18 / $7,437.46
| Facility | | $459.43 | $1,438.18 | $7,437.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.44 / $886.19 / $2,279.84
| Professional | | $474.44 | $886.19 | $2,279.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.92 / $830.26 / $1,186.08
| Professional | | $481.92 | $830.26 | $1,186.08 |