- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.44 / $1,190.44 / $1,428.53
| Facility | | $1,190.44 | $1,190.44 | $1,428.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,428.53
| Professional | | $1,237.28 | $1,237.28 | $1,428.53 |
- 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
- $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
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,795.79
| Professional | | $1,237.28 | $1,237.28 | $1,795.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,427.66
| Professional | | $1,237.28 | $1,237.28 | $1,427.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.60 / $443.19 / $483.48
| Professional | | $336.60 | $443.19 | $483.48 |