- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,801.18 / $1,801.18 / $4,624.64
| Facility | | $1,801.18 | $1,801.18 | $4,624.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.18 / $2,427.59 / $4,624.64
| Professional | | $1,801.18 | $2,427.59 | $4,624.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,559.44 / $5,559.44 / $5,559.44
| Facility | | $5,559.44 | $5,559.44 | $5,559.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,504.26 / $2,547.31 / $5,559.44
| Professional | | $2,504.26 | $2,547.31 | $5,559.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,006.81 / $4,092.73
| Facility | | $3,006.81 | $3,006.81 | $4,092.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $3,006.81 / $3,674.25
| Professional | | $2,194.96 | $3,006.81 | $3,674.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,091.54 / $4,447.55 / $7,227.27
| Professional | | $3,091.54 | $4,447.55 | $7,227.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.74 / $2,238.19 / $3,466.94
| Professional | | $1,628.74 | $2,238.19 | $3,466.94 |