- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,071.52 / $1,288.25
| Professional | | $1,023.29 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $5,011.87
| Facility | | $3,162.28 | $3,715.35 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,096.48
| Professional | | $1,071.52 | $1,071.52 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,230.27
| Professional | | $1,096.48 | $1,096.48 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $1,000.00
| Facility | | $691.83 | $812.83 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $1,230.27
| Professional | | $870.96 | $1,071.52 | $1,230.27 |