- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $5,888.44
| Facility | | $1,445.44 | $1,949.84 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $2,238.72
| Professional | | $1,288.25 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $5,248.07
| Facility | | $1,258.93 | $1,258.93 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,818.38
| Professional | | $2,344.23 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $3,388.44
| Facility | | $1,445.44 | $1,949.84 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $7,244.36
| Professional | | $812.83 | $812.83 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,949.84 / $2,344.23
| Facility | | $812.83 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,288.25
| Professional | | $812.83 | $812.83 | $1,288.25 |