- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $6,760.83
| Facility | | $1,698.24 | $2,290.87 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $2,187.76
| Professional | | $1,513.56 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $6,025.60
| Facility | | $1,479.11 | $1,479.11 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,311.31
| Professional | | $2,754.23 | $2,754.23 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $3,981.07
| Facility | | $1,698.24 | $2,290.87 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $8,511.38
| Professional | | $954.99 | $954.99 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $2,290.87 / $2,754.23
| Facility | | $954.99 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $1,513.56
| Professional | | $954.99 | $954.99 | $1,513.56 |