- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,332.54 / $1,332.54 / $1,332.54
| Facility | | $1,332.54 | $1,332.54 | $1,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.08 / $1,819.02 / $6,678.71
| Professional | | $1,088.08 | $1,819.02 | $6,678.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,349.13 / $1,349.13 / $1,349.13
| Facility | | $1,349.13 | $1,349.13 | $1,349.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.86 / $984.86 / $2,562.67
| Professional | | $984.86 | $984.86 | $2,562.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.44 / $2,415.55 / $3,623.32
| Professional | | $1,932.44 | $2,415.55 | $3,623.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.49 / $583.49 / $1,815.30
| Facility | | $583.49 | $583.49 | $1,815.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.86 / $1,349.13 / $2,313.30
| Professional | | $984.86 | $1,349.13 | $2,313.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.65 / $903.82 / $1,361.78
| Professional | | $835.65 | $903.82 | $1,361.78 |