- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,090.30 / $3,467.37
| Professional | | $1,862.09 | $3,090.30 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,630.78 / $3,630.78
| Facility | | $1,862.09 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,041.74 / $3,890.45
| Professional | | $1,621.81 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $4,073.80 / $5,495.41
| Facility | | $436.52 | $4,073.80 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,454.71
| Professional | | $1,698.24 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $588.84 / $3,715.35
| Facility | | $295.12 | $588.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,884.03 / $4,365.16
| Professional | | $1,230.27 | $2,884.03 | $4,365.16 |