- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,725.04
| Facility | | $1,452.25 | $1,452.25 | $1,725.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,495.82
| Professional | | $1,452.25 | $1,452.25 | $1,495.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.87 / $238.87 / $238.87
| Facility | | $238.87 | $238.87 | $238.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.87 / $238.87 / $238.87
| Professional | | $238.87 | $238.87 | $238.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.05 / $1,370.05 / $1,452.25
| Facility | | $1,370.05 | $1,370.05 | $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
- $1,539.39 / $1,725.04 / $2,355.27
| Facility | | $1,539.39 | $1,725.04 | $2,355.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.96 / $1,597.48 / $1,960.54
| Professional | | $1,582.96 | $1,597.48 | $1,960.54 |
- 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 |