- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,268.16 / $2,370.40 / $3,555.60
| Facility | | $1,268.16 | $2,370.40 | $3,555.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.72 / $2,742.96 / $2,742.96
| Professional | | $983.72 | $2,742.96 | $2,742.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $948.16 / $3,738.12 / $5,908.22
| Facility | | $948.16 | $3,738.12 | $5,908.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.86 / $948.16 / $6,282.75
| Professional | | $651.86 | $948.16 | $6,282.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Facility | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Professional | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,690.00 / $5,234.64
| Facility | | $1,046.93 | $1,690.00 | $5,234.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,185.20 / $1,185.20
| Professional | | $1,185.20 | $1,185.20 | $1,185.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,185.20 / $1,185.20
| Professional | | $1,185.20 | $1,185.20 | $1,185.20 |