- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.66 / $1,370.66 / $1,644.79
| Facility | | $1,370.66 | $1,370.66 | $1,644.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.23 / $1,370.66 / $1,424.50
| Professional | | $1,179.23 | $1,370.66 | $1,424.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.50 / $1,467.50 / $1,467.50
| Professional | | $1,467.50 | $1,467.50 | $1,467.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.65 / $1,491.30 / $1,491.30
| Professional | | $160.65 | $1,491.30 | $1,491.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.64 / $640.09 / $1,178.09
| Facility | | $87.64 | $640.09 | $1,178.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.13 / $1,035.20 / $2,206.82
| Professional | | $690.13 | $1,035.20 | $2,206.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.63 / $2,036.06 / $2,591.34
| Professional | | $1,837.63 | $2,036.06 | $2,591.34 |