- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $6,606.93
| Facility | | $1,659.59 | $2,187.76 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,659.59 / $2,511.89
| Professional | | $1,548.82 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $5,888.44
| Facility | | $1,445.44 | $1,445.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,235.94
| Professional | | $2,691.53 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $3,801.89
| Facility | | $1,621.81 | $2,187.76 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $8,317.64
| Professional | | $933.25 | $933.25 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,187.76 / $2,630.27
| Facility | | $933.25 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,445.44
| Professional | | $933.25 | $933.25 | $1,445.44 |