- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,259.10 / $1,259.10 / $3,232.85
| Facility | | $1,259.10 | $1,259.10 | $3,232.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.10 / $1,748.85 / $3,232.85
| Professional | | $1,259.10 | $1,748.85 | $3,232.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,886.33 / $3,886.33 / $3,886.33
| Facility | | $3,886.33 | $3,886.33 | $3,886.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.69 / $1,932.42 / $4,236.99
| Professional | | $1,917.69 | $1,932.42 | $4,236.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,476.09 / $2,476.09 / $2,861.02
| Facility | | $2,476.09 | $2,476.09 | $2,861.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $2,422.89 / $2,568.48
| Professional | | $1,807.55 | $2,422.89 | $2,568.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.15 / $3,109.06 / $5,052.22
| Professional | | $2,161.15 | $3,109.06 | $5,052.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.78 / $1,585.34 / $2,596.73
| Professional | | $1,465.78 | $1,585.34 | $2,596.73 |