- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,818.38
| Facility | | $1,737.80 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $912.01 / $1,445.44
| Professional | | $588.84 | $912.01 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $831.76 / $1,122.02
| Professional | | $338.84 | $831.76 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,089.30
| Professional | | $1,737.80 | $1,737.80 | $2,089.30 |
- 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
- $602.56 / $912.01 / $1,659.59
| Professional | | $602.56 | $912.01 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,548.82 / $1,737.80
| Professional | | $676.08 | $1,548.82 | $1,737.80 |