- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.81 / $1,357.81 / $1,357.81
| Facility | | $1,357.81 | $1,357.81 | $1,357.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.06 / $1,357.81 / $2,408.92
| Professional | | $936.06 | $1,357.81 | $2,408.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,715.61 / $3,051.26 / $5,539.84
| Facility | | $2,715.61 | $3,051.26 | $5,539.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.81 / $1,526.81 / $1,648.95
| Professional | | $1,526.81 | $1,526.81 | $1,648.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $2,119.51
| Facility | | $2,119.51 | $2,119.51 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $1,547.24 / $2,701.86
| Professional | | $1,547.24 | $1,547.24 | $2,701.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.65 / $1,357.81 / $3,408.79
| Facility | | $808.65 | $1,357.81 | $3,408.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.65 / $808.65 / $808.65
| Professional | | $808.65 | $808.65 | $808.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.40 / $3,394.51 / $5,431.22
| Professional | | $1,982.40 | $3,394.51 | $5,431.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.10 / $1,252.58 / $1,930.19
| Professional | | $1,158.10 | $1,252.58 | $1,930.19 |