- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.27 / $1,272.27 / $1,272.27
| Facility | | $1,272.27 | $1,272.27 | $1,272.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.62 / $885.76 / $1,417.21
| Professional | | $470.62 | $885.76 | $1,417.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.89 / $1,292.77 / $1,371.24
| Facility | | $1,184.89 | $1,292.77 | $1,371.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.18 / $1,283.18 / $1,283.18
| Professional | | $1,283.18 | $1,283.18 | $1,283.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $913.06 / $913.06 / $913.06
| Facility | | $913.06 | $913.06 | $913.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.53 / $913.06 / $2,801.25
| Professional | | $666.53 | $913.06 | $2,801.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $470.62 / $1,363.63 / $7,602.61
| Facility | | $470.62 | $1,363.63 | $7,602.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.00 / $968.80 / $2,161.64
| Professional | | $486.00 | $968.80 | $2,161.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.75 / $844.12 / $1,130.55
| Professional | | $562.75 | $844.12 | $1,130.55 |