- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.46 / $1,201.46 / $3,084.82
| Facility | | $1,201.46 | $1,201.46 | $3,084.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.46 / $1,521.92 / $3,084.82
| Professional | | $1,201.46 | $1,521.92 | $3,084.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,708.36 / $3,708.36 / $3,708.36
| Facility | | $3,708.36 | $3,708.36 | $3,708.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.90 / $1,744.37 / $3,807.05
| Professional | | $1,714.90 | $1,744.37 | $3,807.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.15 / $1,784.15 / $2,730.01
| Facility | | $1,784.15 | $1,784.15 | $2,730.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.43 / $1,784.15 / $2,450.85
| Professional | | $1,302.43 | $1,784.15 | $2,450.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.17 / $2,966.69 / $4,820.87
| Professional | | $2,062.17 | $2,966.69 | $4,820.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.34 / $1,424.47 / $2,374.12
| Professional | | $1,115.34 | $1,424.47 | $2,374.12 |