- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,972.39 / $1,972.39 / $5,064.24
| Facility | | $1,972.39 | $1,972.39 | $5,064.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.39 / $2,433.71 / $5,064.24
| Professional | | $1,972.39 | $2,433.71 | $5,064.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,087.90 / $6,087.90 / $6,087.90
| Facility | | $6,087.90 | $6,087.90 | $6,087.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,776.59 / $2,776.59 / $6,087.90
| Professional | | $2,776.59 | $2,776.59 | $6,087.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $2,853.06 / $4,481.78
| Facility | | $2,853.06 | $2,853.06 | $4,481.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.73 / $2,853.06 / $4,023.51
| Professional | | $2,082.73 | $2,853.06 | $4,023.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,385.41 / $4,870.32 / $7,914.27
| Professional | | $3,385.41 | $4,870.32 | $7,914.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.56 / $2,277.89 / $3,796.48
| Professional | | $1,783.56 | $2,277.89 | $3,796.48 |