- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.55 / $1,028.55 / $3,970.20
| Facility | | $1,028.55 | $1,028.55 | $3,970.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.55 / $1,054.27 / $1,092.83
| Professional | | $1,028.55 | $1,054.27 | $1,092.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.42 / $1,881.18 / $3,428.51
| Facility | | $1,200.42 | $1,881.18 | $3,428.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.69 / $1,135.69 / $1,135.69
| Professional | | $1,135.69 | $1,135.69 | $1,135.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.83 / $1,092.83 / $1,092.83
| Facility | | $1,092.83 | $1,092.83 | $1,092.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.83 / $1,092.83 / $1,092.83
| Professional | | $1,092.83 | $1,092.83 | $1,092.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.55 / $1,028.55 / $1,601.32
| Facility | | $458.55 | $1,028.55 | $1,601.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $3,495.00 / $5,542.17
| Professional | | $155.00 | $3,495.00 | $5,542.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.41 / $1,071.41 / $1,135.69
| Professional | | $1,071.41 | $1,071.41 | $1,135.69 |