- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,391.83 / $1,391.83 / $1,391.83
| Facility | | $1,391.83 | $1,391.83 | $1,391.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.02 / $1,391.83 / $1,528.66
| Professional | | $1,195.02 | $1,391.83 | $1,528.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.75 / $926.75 / $1,684.23
| Facility | | $926.75 | $926.75 | $1,684.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.38 / $1,945.64 / $2,407.96
| Professional | | $1,926.38 | $1,945.64 | $2,407.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.49 / $2,352.19 / $7,755.74
| Facility | | $1,188.49 | $2,352.19 | $7,755.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.62 / $1,041.25 / $1,760.25
| Professional | | $623.62 | $1,041.25 | $1,760.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.40 / $1,684.23 / $3,218.52
| Facility | | $1,400.40 | $1,684.23 | $3,218.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.38 / $1,707.92 / $3,218.52
| Professional | | $1,379.38 | $1,707.92 | $3,218.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.71 / $1,528.66 / $1,817.06
| Professional | | $1,305.71 | $1,528.66 | $1,817.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.35 / $986.56 / $1,760.25
| Professional | | $579.35 | $986.56 | $1,760.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.50 / $1,500.50 / $1,500.50
| Professional | | $1,500.50 | $1,500.50 | $1,500.50 |