- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $7,244.36
| Facility | | $1,778.28 | $2,344.23 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $3,467.37
| Professional | | $1,778.28 | $1,778.28 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $6,918.31 / $10,964.78
| Facility | | $3,801.89 | $6,918.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $724.44
| Professional | | $660.69 | $660.69 | $724.44 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $26,302.68
| Facility | | $2,290.87 | $2,754.23 | $26,302.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,467.37 / $3,467.37
| Facility | | $1,479.11 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $4,897.79
| Professional | | $1,479.11 | $1,737.80 | $4,897.79 |