- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,726.64 / $1,726.64 / $4,433.26
| Facility | | $1,726.64 | $1,726.64 | $4,433.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.64 / $2,398.21 / $4,433.26
| Professional | | $1,726.64 | $2,398.21 | $4,433.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,329.38 / $5,329.38 / $5,329.38
| Facility | | $5,329.38 | $5,329.38 | $5,329.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.21 / $2,670.21 / $5,827.68
| Professional | | $2,670.21 | $2,670.21 | $5,827.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,523.90 / $3,523.90 / $3,923.35
| Facility | | $3,523.90 | $3,523.90 | $3,923.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.44 / $3,448.16 / $3,629.62
| Professional | | $2,572.44 | $3,448.16 | $3,629.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,963.60 / $4,263.50 / $6,928.19
| Professional | | $2,963.60 | $4,263.50 | $6,928.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.07 / $2,658.77 / $3,560.93
| Professional | | $2,016.07 | $2,658.77 | $3,560.93 |