- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,610.24 / $1,610.24 / $4,134.41
| Facility | | $1,610.24 | $1,610.24 | $4,134.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.24 / $2,236.55 / $4,134.41
| Professional | | $1,610.24 | $2,236.55 | $4,134.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,970.12 / $4,970.12 / $4,970.12
| Facility | | $4,970.12 | $4,970.12 | $4,970.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,732.14 / $2,779.11 / $6,065.33
| Professional | | $2,732.14 | $2,779.11 | $6,065.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,658.89
| Facility | | $3,294.10 | $3,294.10 | $3,658.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $3,223.30 / $3,511.67
| Professional | | $2,404.69 | $3,223.30 | $3,511.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,763.82 / $3,976.10 / $6,461.16
| Professional | | $2,763.82 | $3,976.10 | $6,461.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.95 / $2,269.44 / $3,782.41
| Professional | | $1,776.95 | $2,269.44 | $3,782.41 |