- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $3,023.07 / $9,467.04
| Facility | | $1,857.07 | $3,023.07 | $9,467.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $1,857.07
| Professional | | $1,857.07 | $1,857.07 | $1,857.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.86 / $2,039.14 / $2,039.14
| Facility | | $755.86 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.14 / $2,039.14 / $2,039.14
| Professional | | $2,039.14 | $2,039.14 | $2,039.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.07 / $1,857.07 / $1,857.07
| Facility | | $1,857.07 | $1,857.07 | $1,857.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.34 / $1,753.34 / $1,753.34
| Professional | | $1,753.34 | $1,753.34 | $1,753.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.28 / $1,875.28 / $2,362.85
| Professional | | $1,875.28 | $1,875.28 | $2,362.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.66 / $1,820.66 / $1,820.66
| Professional | | $1,820.66 | $1,820.66 | $1,820.66 |