- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,454.71
| Facility | | $1,513.56 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,148.15 / $1,513.56
| Professional | | $831.76 | $1,148.15 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $724.44 / $977.24
| Professional | | $239.88 | $724.44 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,819.70
| Professional | | $1,513.56 | $1,513.56 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $2,344.23
| Professional | | $831.76 | $1,174.90 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,513.56 / $2,187.76
| Professional | | $912.01 | $1,513.56 | $2,187.76 |