- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.39 / $1,035.39 / $2,658.44
| Facility | | $1,035.39 | $1,035.39 | $2,658.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.39 / $1,438.11 / $2,658.44
| Professional | | $1,035.39 | $1,438.11 | $2,658.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,195.81 / $3,195.81 / $3,195.81
| Facility | | $3,195.81 | $3,195.81 | $3,195.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.37 / $1,722.19 / $3,672.67
| Professional | | $1,654.37 | $1,722.19 | $3,672.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.13 / $2,084.13 / $2,352.67
| Facility | | $2,084.13 | $2,084.13 | $2,352.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.41 / $2,084.13 / $2,221.79
| Professional | | $1,521.41 | $2,084.13 | $2,221.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.16 / $2,556.65 / $4,154.55
| Professional | | $1,777.16 | $2,556.65 | $4,154.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,037.61 / $1,815.91 / $2,061.29
| Facility | | $1,037.61 | $1,815.91 | $2,061.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.98 / $1,374.19 / $2,135.36
| Professional | | $1,075.98 | $1,374.19 | $2,135.36 |