- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,432.05 / $1,432.05 / $3,676.88
| Facility | | $1,432.05 | $1,432.05 | $3,676.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.05 / $1,766.99 / $3,676.88
| Professional | | $1,432.05 | $1,766.99 | $3,676.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,420.10 / $4,420.10 / $4,420.10
| Facility | | $4,420.10 | $4,420.10 | $4,420.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.05 / $2,025.27 / $4,420.10
| Professional | | $1,991.05 | $2,025.27 | $4,420.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $3,253.98
| Facility | | $2,637.76 | $2,637.76 | $3,253.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,623.38 / $2,921.26
| Professional | | $1,925.56 | $2,623.38 | $2,921.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,457.96 / $3,536.09 / $5,746.14
| Professional | | $2,457.96 | $3,536.09 | $5,746.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.12 / $1,779.50 / $2,756.43
| Professional | | $1,529.12 | $1,779.50 | $2,756.43 |