- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,560.56 / $1,560.56 / $4,006.83
| Facility | | $1,560.56 | $1,560.56 | $4,006.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.56 / $2,128.57 / $4,006.83
| Professional | | $1,560.56 | $2,128.57 | $4,006.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,816.75 / $4,816.75 / $4,816.75
| Facility | | $4,816.75 | $4,816.75 | $4,816.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,381.38 / $2,396.26 / $5,286.63
| Professional | | $2,381.38 | $2,396.26 | $5,286.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $3,545.98
| Facility | | $2,728.17 | $2,728.17 | $3,545.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $4,407.37
| Professional | | $1,991.56 | $1,991.56 | $4,407.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,678.54 / $3,853.40 / $6,261.78
| Professional | | $2,678.54 | $3,853.40 | $6,261.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,574.73 / $3,218.43
| Professional | | $1,548.82 | $2,574.73 | $3,218.43 |