- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $5,248.07
| Facility | | $1,513.56 | $1,513.56 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,344.23 / $2,884.03
| Professional | | $1,513.56 | $2,344.23 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,677.35
| Facility | | $3,388.44 | $3,388.44 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $4,265.80
| Professional | | $2,884.03 | $2,884.03 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,890.45 / $5,623.41
| Facility | | $1,949.84 | $3,890.45 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,019.95
| Facility | | $2,691.53 | $2,691.53 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,019.95
| Professional | | $1,258.93 | $1,819.70 | $3,019.95 |