- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,660.64 / $1,660.64 / $1,660.64
| Facility | | $1,660.64 | $1,660.64 | $1,660.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.06 / $1,660.64 / $1,660.64
| Professional | | $1,453.06 | $1,660.64 | $1,660.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,577.30 / $1,714.92 / $4,324.67
| Facility | | $1,577.30 | $1,714.92 | $4,324.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,385.08 / $2,385.08 / $2,981.34
| Professional | | $2,385.08 | $2,385.08 | $2,981.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.06 / $1,660.64 / $2,075.80
| Facility | | $1,453.06 | $1,660.64 | $2,075.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.27 / $2,075.80 / $2,075.80
| Professional | | $1,349.27 | $2,075.80 | $2,075.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,490.96 / $2,490.96 / $2,490.96
| Facility | | $2,490.96 | $2,490.96 | $2,490.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.11 / $1,037.90 / $2,075.80
| Professional | | $934.11 | $1,037.90 | $2,075.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,611.89 / $9,860.04 / $9,860.04
| Facility | | $3,611.89 | $9,860.04 | $9,860.04 |