- 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
- $1,148.15 / $1,202.26 / $1,445.44
| Professional | | $1,148.15 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,949.84
| Professional | | $1,148.15 | $1,148.15 | $1,949.84 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $478.63 / $478.63
| Professional | | $467.74 | $478.63 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $1,949.84
| Facility | | $1,000.00 | $1,348.96 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,445.44 / $1,445.44
| Professional | | $1,380.38 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $302.00 / $1,148.15
| Facility | | $245.47 | $302.00 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $302.00 / $1,148.15
| Professional | | $245.47 | $302.00 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,258.93
| Professional | | $1,202.26 | $1,202.26 | $1,258.93 |