- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.11 / $1,172.11 / $3,009.51
| Facility | | $1,172.11 | $1,172.11 | $3,009.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.11 / $1,498.12 / $3,009.51
| Professional | | $1,172.11 | $1,498.12 | $3,009.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,617.83 / $3,617.83 / $3,617.83
| Facility | | $3,617.83 | $3,617.83 | $3,617.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.85 / $1,660.84 / $3,651.55
| Professional | | $1,644.85 | $1,660.84 | $3,651.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.28 / $1,711.28 / $2,627.45
| Facility | | $1,711.28 | $1,711.28 | $2,627.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.23 / $1,711.28 / $2,391.03
| Professional | | $1,249.23 | $1,711.28 | $2,391.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.84 / $2,894.26 / $4,703.18
| Professional | | $2,011.84 | $2,894.26 | $4,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.79 / $1,470.09 / $2,277.15
| Professional | | $1,069.79 | $1,470.09 | $2,277.15 |