- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,608.56 / $1,608.56 / $1,856.03
| Facility | | $1,608.56 | $1,608.56 | $1,856.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.41 / $1,608.56 / $1,884.13
| Professional | | $1,523.41 | $1,608.56 | $1,884.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,710.32 / $4,710.32 / $4,710.32
| Facility | | $4,710.32 | $4,710.32 | $4,710.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.73 / $2,151.62 / $4,710.32
| Professional | | $2,068.73 | $2,151.62 | $4,710.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.59 / $2,507.59 / $3,467.63
| Facility | | $2,507.59 | $2,507.59 | $3,467.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $2,507.59 / $3,113.06
| Professional | | $1,830.54 | $2,507.59 | $3,113.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,619.36 / $3,768.26 / $6,123.42
| Professional | | $2,619.36 | $3,768.26 | $6,123.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.98 / $1,762.45 / $2,937.41
| Professional | | $1,379.98 | $1,762.45 | $2,937.41 |