- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,527.42 / $1,527.42 / $3,921.75
| Facility | | $1,527.42 | $1,527.42 | $3,921.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.42 / $2,121.52 / $3,921.75
| Professional | | $1,527.42 | $2,121.52 | $3,921.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,714.47 / $4,714.47 / $4,714.47
| Facility | | $4,714.47 | $4,714.47 | $4,714.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.62 / $2,902.12 / $5,753.36
| Professional | | $2,591.62 | $2,902.12 | $5,753.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $3,470.68
| Facility | | $2,886.72 | $2,886.72 | $3,470.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,886.72 / $3,077.39
| Professional | | $2,107.31 | $2,886.72 | $3,077.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,621.66 / $3,771.58 / $6,128.82
| Professional | | $2,621.66 | $3,771.58 | $6,128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,685.55 / $2,152.71 / $3,317.27
| Professional | | $1,685.55 | $2,152.71 | $3,317.27 |