- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,466.78 / $1,495.82
| Facility | | $1,452.25 | $1,466.78 | $1,495.82 |
- 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
- $1,710.00 / $1,710.00 / $2,565.00
| Facility | | $1,710.00 | $1,710.00 | $2,565.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.00 / $1,710.00 / $1,744.20
| Professional | | $1,710.00 | $1,710.00 | $1,744.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.37 / $121.37 / $121.37
| Facility | | $121.37 | $121.37 | $121.37 |
- 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
- $164.50 / $164.50 / $164.50
| Facility | | $164.50 | $164.50 | $164.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.87 / $1,452.25 / $1,815.31
| Professional | | $1,379.87 | $1,452.25 | $1,815.31 |