- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,151.45 / $1,151.45 / $1,151.45
| Facility | | $1,151.45 | $1,151.45 | $1,151.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.45 / $1,151.45 / $1,357.68
| Professional | | $1,151.45 | $1,151.45 | $1,357.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,586.93 / $1,745.63 / $1,763.26
| Professional | | $1,586.93 | $1,745.63 | $1,763.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,316.65 / $1,986.14 / $1,986.14
| Facility | | $1,316.65 | $1,986.14 | $1,986.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.65 / $1,986.14 / $3,062.67
| Professional | | $1,316.65 | $1,986.14 | $3,062.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.72 / $1,976.37 / $9,399.59
| Facility | | $1,019.72 | $1,976.37 | $9,399.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.43 / $1,153.38 / $1,501.31
| Professional | | $687.43 | $1,153.38 | $1,501.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,980.33 / $1,986.14 / $2,699.76
| Facility | | $1,980.33 | $1,986.14 | $2,699.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.44 / $2,373.03 / $4,091.78
| Professional | | $1,651.44 | $2,373.03 | $4,091.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.43 / $1,098.46 / $1,366.23
| Professional | | $687.43 | $1,098.46 | $1,366.23 |