- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,238.72
| Facility | | $870.96 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,096.48 / $2,238.72
| Professional | | $912.01 | $1,096.48 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,890.45
| Facility | | $2,398.83 | $2,884.03 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $2,454.71
| Professional | | $1,412.54 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $2,290.87
| Professional | | $812.83 | $1,202.26 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,737.80 / $3,388.44
| Facility | | $645.65 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,737.80
| Professional | | $776.25 | $1,000.00 | $1,737.80 |