- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,192.15 / $1,192.15 / $3,060.92
| Facility | | $1,192.15 | $1,192.15 | $3,060.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.15 / $1,655.84 / $3,060.92
| Professional | | $1,192.15 | $1,655.84 | $3,060.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,679.64 / $3,679.64 / $3,679.64
| Facility | | $3,679.64 | $3,679.64 | $3,679.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.44 / $2,060.88 / $4,518.63
| Professional | | $2,035.44 | $2,060.88 | $4,518.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $2,708.87
| Facility | | $2,677.88 | $2,677.88 | $2,708.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,386.38 / $2,854.76
| Professional | | $1,954.85 | $2,386.38 | $2,854.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,046.21 / $2,943.71 / $4,783.53
| Professional | | $2,046.21 | $2,943.71 | $4,783.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.82 / $1,690.72 / $2,605.35
| Professional | | $1,323.82 | $1,690.72 | $2,605.35 |