- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $1,445.44 / $1,737.80
| Facility | | $239.88 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,698.24
| Professional | | $1,445.44 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $4,570.88
| Facility | | $1,445.44 | $1,778.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,445.44 / $2,818.38
| Professional | | $125.89 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,445.44 / $2,570.40
| Facility | | $1,380.38 | $1,445.44 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $2,041.74
| Professional | | $1,445.44 | $1,445.44 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $3,235.94
| Facility | | $1,659.59 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,659.59 / $2,511.89
| Professional | | $125.89 | $1,659.59 | $2,511.89 |