- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,414.46 / $1,414.46 / $3,631.72
| Facility | | $1,414.46 | $1,414.46 | $3,631.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.46 / $1,745.28 / $3,631.72
| Professional | | $1,414.46 | $1,745.28 | $3,631.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.81 / $4,365.81 / $4,365.81
| Facility | | $4,365.81 | $4,365.81 | $4,365.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.59 / $2,000.39 / $4,365.81
| Professional | | $1,966.59 | $2,000.39 | $4,365.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,694.60 / $2,694.60 / $3,214.01
| Facility | | $2,694.60 | $2,694.60 | $3,214.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.06 / $1,967.06 / $3,159.44
| Professional | | $1,967.06 | $1,967.06 | $3,159.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.78 / $3,492.65 / $5,675.55
| Professional | | $2,427.78 | $3,492.65 | $5,675.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,279.04 / $1,633.54 / $2,722.57
| Professional | | $1,279.04 | $1,633.54 | $2,722.57 |