- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,513.56
| Facility | | $1,148.15 | $1,148.15 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,174.90 / $1,445.44
| Professional | | $1,148.15 | $1,174.90 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $331.13 / $446.68
| Professional | | $302.00 | $331.13 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $977.24 / $977.24
| Professional | | $549.54 | $977.24 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $3,162.28
| Facility | | $1,148.15 | $1,380.38 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,202.26 / $5,495.41
| Professional | | $1,148.15 | $1,202.26 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $489.78 / $1,230.27
| Facility | | $478.63 | $489.78 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,258.93
| Professional | | $1,071.52 | $1,202.26 | $1,258.93 |