- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,775.30 / $2,219.13 / $5,325.91
| Facility | | $1,775.30 | $2,219.13 | $5,325.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.35 / $1,664.35 / $1,775.30
| Professional | | $1,664.35 | $1,664.35 | $1,775.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,442.43 / $1,442.43 / $1,947.28
| Facility | | $1,442.43 | $1,442.43 | $1,947.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,331.48 / $1,664.35 / $7,434.09
| Facility | | $1,331.48 | $1,664.35 | $7,434.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $932.03 / $2,219.13
| Professional | | $932.03 | $932.03 | $2,219.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $932.03 / $1,331.48
| Professional | | $932.03 | $932.03 | $1,331.48 |