- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.72 / $1,233.72 / $3,167.67
| Facility | | $1,233.72 | $1,233.72 | $3,167.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.72 / $1,579.75 / $3,167.67
| Professional | | $1,233.72 | $1,579.75 | $3,167.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,807.96 / $3,807.96 / $3,807.96
| Facility | | $3,807.96 | $3,807.96 | $3,807.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.30 / $1,715.30 / $3,807.96
| Professional | | $1,715.30 | $1,715.30 | $3,807.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,803.34
| Facility | | $2,050.41 | $2,050.41 | $2,803.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $3,173.81
| Professional | | $1,496.80 | $1,496.80 | $3,173.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.56 / $3,046.37 / $4,950.35
| Professional | | $2,117.56 | $3,046.37 | $4,950.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.35 / $1,424.81 / $2,374.69
| Professional | | $1,317.35 | $1,424.81 | $2,374.69 |