- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.34 / $1,185.34 / $3,043.48
| Facility | | $1,185.34 | $1,185.34 | $3,043.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.34 / $1,468.88 / $3,043.48
| Professional | | $1,185.34 | $1,468.88 | $3,043.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,658.67 / $3,658.67 / $3,658.67
| Facility | | $3,658.67 | $3,658.67 | $3,658.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.14 / $1,972.92 / $3,674.38
| Professional | | $1,655.14 | $1,972.92 | $3,674.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,721.98 / $1,721.98 / $2,693.44
| Facility | | $1,721.98 | $1,721.98 | $2,693.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.05 / $1,721.98 / $2,276.48
| Professional | | $1,257.05 | $1,721.98 | $2,276.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.55 / $2,926.94 / $4,756.27
| Professional | | $2,034.55 | $2,926.94 | $4,756.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.48 / $1,374.83 / $2,291.39
| Professional | | $1,076.48 | $1,374.83 | $2,291.39 |