- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,648.76 / $2,440.17 / $5,276.04
| Facility | | $1,648.76 | $2,440.17 | $5,276.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.78 / $1,626.78 / $1,648.76
| Professional | | $1,626.78 | $1,626.78 | $1,648.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.93 / $1,428.93 / $5,872.90
| Facility | | $1,428.93 | $1,428.93 | $5,872.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,677.46 / $2,677.46 / $3,207.90
| Professional | | $2,677.46 | $2,677.46 | $3,207.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,626.78 / $2,198.35 / $3,693.23
| Facility | | $1,626.78 | $2,198.35 | $3,693.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $923.31 / $8,255.31
| Professional | | $923.31 | $923.31 | $8,255.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $923.31 / $2,198.35
| Professional | | $923.31 | $923.31 | $2,198.35 |