- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $3,715.35
| Facility | | $2,290.87 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,737.80 / $2,187.76
| Professional | | $1,202.26 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $14,454.40 / $15,848.93
| Facility | | $12,589.25 | $14,454.40 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,380.38 / $2,187.76
| Professional | | $794.33 | $1,380.38 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,754.23
| Professional | | $2,290.87 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $2,187.76
| Professional | | $1,230.27 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,290.87 / $3,388.44
| Professional | | $1,380.38 | $2,290.87 | $3,388.44 |