- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,159.42 / $1,159.42 / $1,159.42
| Facility | | $1,159.42 | $1,159.42 | $1,159.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.15 / $1,159.42 / $1,178.50
| Professional | | $956.15 | $1,159.42 | $1,178.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.43 / $895.43 / $1,347.58
| Facility | | $895.43 | $895.43 | $1,347.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.31 / $1,604.63 / $2,005.78
| Professional | | $1,538.31 | $1,604.63 | $2,005.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.48 / $1,362.34 / $5,814.95
| Facility | | $850.48 | $1,362.34 | $5,814.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.77 / $802.74 / $1,400.41
| Professional | | $480.77 | $802.74 | $1,400.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.48 / $1,347.58 / $2,139.61
| Facility | | $1,120.48 | $1,347.58 | $2,139.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.66 / $1,366.53 / $2,575.19
| Professional | | $1,103.66 | $1,366.53 | $2,575.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.61 / $1,178.50 / $1,400.83
| Professional | | $1,006.61 | $1,178.50 | $1,400.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.52 / $802.74 / $1,384.22
| Professional | | $435.52 | $802.74 | $1,384.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.57 / $1,200.57 / $1,200.57
| Professional | | $1,200.57 | $1,200.57 | $1,200.57 |