- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.93 / $1,397.42 / $8,067.74
| Facility | | $1,117.93 | $1,397.42 | $8,067.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.93 / $1,304.26 / $1,676.90
| Professional | | $1,117.93 | $1,304.26 | $1,676.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.67 / $1,226.23 / $2,670.45
| Facility | | $919.67 | $1,226.23 | $2,670.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.44 / $2,269.44 / $2,719.06
| Professional | | $2,269.44 | $2,269.44 | $2,719.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.93 / $1,117.93 / $1,628.60
| Professional | | $1,117.93 | $1,117.93 | $1,628.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,863.22 / $1,863.22 / $2,794.83
| Facility | | $1,863.22 | $1,863.22 | $2,794.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.13 / $782.55 / $4,285.41
| Professional | | $652.13 | $782.55 | $4,285.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.93 / $1,117.93 / $1,117.93
| Professional | | $1,117.93 | $1,117.93 | $1,117.93 |