- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,931.67 / $1,931.67 / $4,959.68
| Facility | | $1,931.67 | $1,931.67 | $4,959.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.67 / $2,383.46 / $4,959.68
| Professional | | $1,931.67 | $2,383.46 | $4,959.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,962.20 / $5,962.20 / $5,962.20
| Facility | | $5,962.20 | $5,962.20 | $5,962.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,685.69 / $2,731.85 / $5,962.20
| Professional | | $2,685.69 | $2,731.85 | $5,962.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $4,389.24
| Facility | | $3,813.78 | $3,813.78 | $4,389.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $3,391.89 / $3,940.42
| Professional | | $2,784.06 | $3,391.89 | $3,940.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,315.52 / $4,769.76 / $7,750.86
| Professional | | $3,315.52 | $4,769.76 | $7,750.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.74 / $2,230.86 / $3,718.10
| Professional | | $1,746.74 | $2,230.86 | $3,718.10 |