- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,361.01 / $1,361.01 / $1,361.01
| Facility | | $1,361.01 | $1,361.01 | $1,361.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,249.66 / $1,361.01
| Professional | | $1,237.28 | $1,249.66 | $1,361.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.54 / $2,011.75 / $4,975.10
| Facility | | $851.54 | $2,011.75 | $4,975.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.84 / $1,064.42 / $2,514.67
| Professional | | $864.84 | $1,064.42 | $2,514.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.25 / $1,237.28 / $1,237.28
| Facility | | $1,167.25 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.56 / $1,309.48 / $2,658.24
| Facility | | $106.56 | $1,309.48 | $2,658.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.44 / $1,190.44 / $2,583.25
| Professional | | $1,190.44 | $1,190.44 | $2,583.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,237.28 / $1,237.28
| Professional | | $1,055.97 | $1,237.28 | $1,237.28 |