- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,127.81 / $1,127.81 / $1,127.81
| Facility | | $1,127.81 | $1,127.81 | $1,127.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.43 / $1,127.81 / $1,871.30
| Professional | | $876.43 | $1,127.81 | $1,871.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,013.95 / $2,262.87 / $4,108.46
| Facility | | $2,013.95 | $2,262.87 | $4,108.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.58 / $1,226.58 / $1,226.58
| Professional | | $1,226.58 | $1,226.58 | $1,226.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,544.16 / $1,544.16
| Facility | | $1,544.16 | $1,544.16 | $1,544.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,127.24 / $2,154.98
| Professional | | $1,127.24 | $1,127.24 | $2,154.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $648.64 / $1,127.81 / $2,533.64
| Facility | | $648.64 | $1,127.81 | $2,533.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.64 / $648.64 / $648.64
| Professional | | $648.64 | $648.64 | $648.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.18 / $2,517.44 / $3,987.62
| Professional | | $1,470.18 | $2,517.44 | $3,987.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.29 / $1,004.74 / $1,513.50
| Professional | | $912.29 | $1,004.74 | $1,513.50 |