- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.05 / $1,227.05 / $1,227.05
| Facility | | $1,227.05 | $1,227.05 | $1,227.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.05 / $1,227.05 / $1,227.05
| Professional | | $1,227.05 | $1,227.05 | $1,227.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.02 / $2,370.96 / $2,963.71
| Professional | | $1,515.02 | $2,370.96 | $2,963.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.00 / $1,478.07 / $6,200.51
| Facility | | $1,232.00 | $1,478.07 | $6,200.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.74 / $1,174.83 / $1,958.06
| Professional | | $665.74 | $1,174.83 | $1,958.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,566.44 / $2,284.40 / $2,568.96
| Facility | | $1,566.44 | $2,284.40 | $2,568.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.44 / $2,284.40 / $2,860.83
| Professional | | $1,566.44 | $2,284.40 | $2,860.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.36 / $3,145.03 / $3,586.11
| Professional | | $1,305.36 | $3,145.03 | $3,586.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.26 / $783.22 / $1,566.44
| Professional | | $548.26 | $783.22 | $1,566.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.36 / $1,305.36 / $1,305.36
| Professional | | $1,305.36 | $1,305.36 | $1,305.36 |