- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,305.36 / $1,305.36 / $2,773.91
| Facility | | $1,305.36 | $1,305.36 | $2,773.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,976.75 / $2,976.75 / $2,976.75
| Professional | | $2,976.75 | $2,976.75 | $2,976.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.15 / $522.15 / $848.49
| Professional | | $522.15 | $522.15 | $848.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.02 / $1,500.02 / $1,875.02
| Professional | | $1,500.02 | $1,500.02 | $1,875.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.36 / $1,305.36 / $1,580.80
| Professional | | $1,305.36 | $1,305.36 | $1,580.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,305.36 / $1,305.36 / $2,114.69
| Facility | | $1,305.36 | $1,305.36 | $2,114.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.36 / $2,976.75 / $2,976.75
| Professional | | $1,305.36 | $2,976.75 | $2,976.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.22 / $783.22 / $1,892.79
| Professional | | $783.22 | $783.22 | $1,892.79 |