- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $5,623.41
| Facility | | $1,412.54 | $1,862.09 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $2,137.96
| Professional | | $1,258.93 | $1,445.44 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $5,011.87
| Facility | | $1,202.26 | $1,202.26 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,691.53
| Professional | | $2,290.87 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $3,235.94
| Facility | | $1,380.38 | $1,862.09 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $2,454.71
| Professional | | $776.25 | $776.25 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,862.09 / $2,238.72
| Facility | | $776.25 | $1,862.09 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $1,230.27
| Professional | | $776.25 | $776.25 | $1,230.27 |