- 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
- $1,258.93 / $1,288.25 / $1,479.11
| Professional | | $1,258.93 | $1,288.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $371.54 / $478.63
| Professional | | $60.26 | $371.54 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $707.95 / $1,380.38
| Facility | | $562.34 | $707.95 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $478.63
| Professional | | $354.81 | $354.81 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $380.19 / $436.52
| Professional | | $363.08 | $380.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $323.59 / $380.19
| Professional | | $302.00 | $323.59 | $380.19 |
- 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 |