- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $863.45 / $1,793.73 / $4,404.14
| Facility | | $863.45 | $1,793.73 | $4,404.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.79 / $1,214.63 / $2,310.23
| Professional | | $1,156.79 | $1,214.63 | $2,310.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.73 / $2,198.48 / $3,898.96
| Facility | | $1,554.73 | $2,198.48 | $3,898.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Facility | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,736.92
| Facility | | $1,214.63 | $1,214.63 | $1,736.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,190.00 / $3,190.00 / $3,190.00
| Professional | | $3,190.00 | $3,190.00 | $3,190.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,214.63
| Professional | | $1,214.63 | $1,214.63 | $1,214.63 |