- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,645.62 / $1,645.62 / $1,898.79
| Facility | | $1,645.62 | $1,645.62 | $1,898.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.62 / $1,898.79 / $2,056.67
| Professional | | $1,645.62 | $1,898.79 | $2,056.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,818.83 / $4,818.83 / $4,818.83
| Facility | | $4,818.83 | $4,818.83 | $4,818.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.40 / $2,828.47 / $5,882.16
| Professional | | $2,583.40 | $2,828.47 | $5,882.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,756.64 / $2,756.64 / $3,547.53
| Facility | | $2,756.64 | $2,756.64 | $3,547.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,662.12 / $2,012.35 / $5,723.63
| Professional | | $1,662.12 | $2,012.35 | $5,723.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.29 / $2,200.91 / $3,157.49
| Professional | | $1,723.29 | $2,200.91 | $3,157.49 |