- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,394.14 / $3,394.14 / $3,657.48
| Facility | | $3,394.14 | $3,394.14 | $3,657.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $1,243.54
| Professional | | $1,243.54 | $1,243.54 | $1,243.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,238.90 / $1,555.12 / $4,057.11
| Facility | | $1,238.90 | $1,555.12 | $4,057.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $1,243.54
| Professional | | $1,243.54 | $1,243.54 | $1,243.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $1,243.54
| Facility | | $1,243.54 | $1,243.54 | $1,243.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $1,243.54
| Professional | | $1,243.54 | $1,243.54 | $1,243.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $1,505.93
| Professional | | $1,243.54 | $1,243.54 | $1,505.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,394.14 / $3,394.14 / $3,657.48
| Facility | | $3,394.14 | $3,394.14 | $3,657.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.54 / $1,243.54 / $3,657.48
| Professional | | $1,243.54 | $1,243.54 | $3,657.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.16 / $1,219.16 / $1,828.74
| Professional | | $1,219.16 | $1,219.16 | $1,828.74 |