- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,174.90 / $1,819.70
| Professional | | $851.14 | $1,174.90 | $1,819.70 |
- 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
- $891.25 / $891.25 / $3,235.94
| Professional | | $891.25 | $891.25 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,187.76 / $3,311.31
| Professional | | $1,737.80 | $2,187.76 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,548.82 / $2,290.87
| Facility | | $630.96 | $1,548.82 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $2,570.40
| Professional | | $891.25 | $891.25 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $2,630.27
| Facility | | $741.31 | $1,071.52 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $977.24 / $1,445.44
| Professional | | $870.96 | $977.24 | $1,445.44 |