- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,802.16 / $1,802.16 / $4,627.17
| Facility | | $1,802.16 | $1,802.16 | $4,627.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.16 / $2,569.56 / $4,627.17
| Professional | | $1,802.16 | $2,569.56 | $4,627.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,562.49 / $5,562.49 / $5,562.49
| Facility | | $5,562.49 | $5,562.49 | $5,562.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,443.26 / $3,443.26 / $9,550.66
| Professional | | $3,443.26 | $3,443.26 | $9,550.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.97 / $3,323.97 / $3,323.97
| Facility | | $3,323.97 | $3,323.97 | $3,323.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.50 / $3,323.97 / $3,423.69
| Professional | | $2,426.50 | $3,323.97 | $3,423.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.31 / $2,244.96 / $3,741.62
| Professional | | $2,136.31 | $2,244.96 | $3,741.62 |