- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,641.12 / $1,641.12 / $4,213.68
| Facility | | $1,641.12 | $1,641.12 | $4,213.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.12 / $2,279.42 / $4,213.68
| Professional | | $1,641.12 | $2,279.42 | $4,213.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,065.39 / $5,065.39 / $5,065.39
| Facility | | $5,065.39 | $5,065.39 | $5,065.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.78 / $2,704.43 / $5,933.53
| Professional | | $2,672.78 | $2,704.43 | $5,933.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $3,729.04
| Facility | | $2,780.72 | $2,780.72 | $3,729.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $3,394.00
| Professional | | $2,029.93 | $2,780.72 | $3,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,816.81 / $4,052.32 / $6,585.02
| Professional | | $2,816.81 | $4,052.32 | $6,585.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,052.69 / $2,220.13 / $3,397.40
| Professional | | $2,052.69 | $2,220.13 | $3,397.40 |