- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,597.48 / $1,597.48 / $1,597.48
| Facility | | $1,597.48 | $1,597.48 | $1,597.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,466.78 / $1,597.48
| Professional | | $1,452.25 | $1,466.78 | $1,597.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,326.52 / $3,133.90 / $7,750.19
| Facility | | $1,326.52 | $3,133.90 | $7,750.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.25 / $1,658.15 / $3,917.38
| Professional | | $1,347.25 | $1,658.15 | $3,917.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.05 / $1,452.25 / $1,452.25
| Facility | | $1,370.05 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,681.91 / $1,966.55 / $3,852.03
| Facility | | $1,681.91 | $1,966.55 | $3,852.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.04 / $1,725.04 / $3,743.34
| Professional | | $1,725.04 | $1,725.04 | $3,743.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $2,033.15
| Facility | | $1,452.25 | $1,452.25 | $2,033.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |