- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,190.44 / $1,237.28 / $2,083.27
| Facility | | $1,190.44 | $1,237.28 | $2,083.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,299.15
| Professional | | $1,237.28 | $1,237.28 | $1,299.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,190.44 / $1,347.67
| Professional | | $1,055.97 | $1,190.44 | $1,347.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Facility | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.00 / $2,408.92 / $5,119.78
| Facility | | $1,428.00 | $2,408.92 | $5,119.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,119.78 / $5,119.78 / $5,563.22
| Professional | | $5,119.78 | $5,119.78 | $5,563.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,237.28 / $1,237.28
| Professional | | $1,055.97 | $1,237.28 | $1,237.28 |