- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.31 / $1,077.31 / $2,766.07
| Facility | | $1,077.31 | $1,077.31 | $2,766.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.31 / $1,496.33 / $2,766.07
| Professional | | $1,077.31 | $1,496.33 | $2,766.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,325.18 / $3,325.18 / $3,325.18
| Facility | | $3,325.18 | $3,325.18 | $3,325.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.39 / $1,876.10 / $4,094.53
| Professional | | $1,844.39 | $1,876.10 | $4,094.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,447.92 / $2,571.77 / $2,571.77
| Facility | | $2,447.92 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $2,429.94 / $2,648.92
| Professional | | $1,877.39 | $2,429.94 | $2,648.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.10 / $2,660.14 / $4,322.72
| Professional | | $1,849.10 | $2,660.14 | $4,322.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.57 / $1,777.43 / $2,360.82
| Professional | | $1,199.57 | $1,777.43 | $2,360.82 |