- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.09 / $1,058.09 / $2,716.74
| Facility | | $1,058.09 | $1,058.09 | $2,716.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.09 / $1,305.96 / $2,716.74
| Professional | | $1,058.09 | $1,305.96 | $2,716.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,265.89 / $3,265.89 / $3,265.89
| Facility | | $3,265.89 | $3,265.89 | $3,265.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.56 / $1,484.70 / $3,266.85
| Professional | | $1,471.56 | $1,484.70 | $3,266.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.17 / $1,787.17 / $2,404.28
| Facility | | $1,787.17 | $1,787.17 | $2,404.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.63 / $1,304.63 / $2,727.06
| Professional | | $1,304.63 | $1,304.63 | $2,727.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.13 / $2,612.71 / $4,245.66
| Professional | | $1,816.13 | $2,612.71 | $4,245.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.21 / $1,448.21 / $1,448.21
| Facility | | $1,448.21 | $1,448.21 | $1,448.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.16 / $1,602.76 / $2,037.24
| Professional | | $1,130.16 | $1,602.76 | $2,037.24 |