- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $3,890.45
| Professional | | $1,122.02 | $1,412.54 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,047.13 / $1,380.38
| Professional | | $524.81 | $1,047.13 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $870.96 / $1,174.90
| Facility | | $724.44 | $870.96 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,288.25 / $1,513.56
| Professional | | $1,202.26 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.20 / $501.19 / $1,445.44
| Facility | | $1.20 | $501.19 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,288.25 / $1,288.25
| Professional | | $512.86 | $1,288.25 | $1,288.25 |