- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $2,398.83
| Facility | | $1,659.59 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,659.59 / $2,398.83
| Professional | | $1,445.44 | $1,659.59 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,238.72 / $2,238.72
| Professional | | $1,445.44 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,570.88 / $7,943.28
| Facility | | $1,445.44 | $4,570.88 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,691.53 / $3,388.44
| Professional | | $2,570.40 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,513.56 / $2,238.72
| Facility | | $794.33 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,238.72
| Professional | | $933.25 | $1,318.26 | $2,238.72 |