- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $8,709.64
| Facility | | $1,412.54 | $1,905.46 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $2,398.83
| Professional | | $1,258.93 | $1,479.11 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $5,011.87
| Facility | | $1,230.27 | $1,230.27 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,754.23
| Professional | | $2,290.87 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $3,311.31
| Facility | | $1,412.54 | $1,905.46 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $7,079.46
| Professional | | $794.33 | $794.33 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,905.46 / $2,290.87
| Facility | | $794.33 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,258.93
| Professional | | $794.33 | $794.33 | $1,258.93 |