- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,457.41 / $2,156.96 / $4,663.70
| Facility | | $1,457.41 | $2,156.96 | $4,663.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.98 / $1,437.98 / $1,457.41
| Professional | | $1,437.98 | $1,437.98 | $1,457.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.08 / $1,263.08 / $5,191.30
| Facility | | $1,263.08 | $1,263.08 | $5,191.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,366.64 / $2,366.64 / $2,835.50
| Professional | | $2,366.64 | $2,366.64 | $2,835.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,437.98 / $1,943.21 / $3,264.59
| Facility | | $1,437.98 | $1,943.21 | $3,264.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $816.15 / $7,297.20
| Professional | | $816.15 | $816.15 | $7,297.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $816.15 / $1,943.21
| Professional | | $816.15 | $816.15 | $1,943.21 |