- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,617.82 / $1,617.82 / $1,617.82
| Facility | | $1,617.82 | $1,617.82 | $1,617.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,375.15 / $1,617.82
| Professional | | $1,294.26 | $1,375.15 | $1,617.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Facility | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.34 / $1,391.33 / $1,989.60
| Facility | | $505.34 | $1,391.33 | $1,989.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.88 / $483.88 / $583.30
| Professional | | $483.88 | $483.88 | $583.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.00 / $78.00 / $78.00
| Professional | | $78.00 | $78.00 | $78.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.46 / $985.46 / $1,209.42
| Facility | | $985.46 | $985.46 | $1,209.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.63 / $1,388.63 / $1,388.63
| Professional | | $1,388.63 | $1,388.63 | $1,388.63 |