- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,318.26
| Professional | | $691.83 | $870.96 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $1,288.25
| Facility | | $1,174.90 | $1,230.27 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Facility | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,905.46
| Professional | | $794.33 | $794.33 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $1,071.52 / $3,467.37
| Facility | | $478.63 | $1,071.52 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $8,709.64
| Professional | | $489.78 | $812.83 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,122.02 / $1,230.27
| Facility | | $436.52 | $1,122.02 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $758.58 / $1,122.02
| Professional | | $512.86 | $758.58 | $1,122.02 |