- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,573.38 / $1,573.38 / $4,039.77
| Facility | | $1,573.38 | $1,573.38 | $4,039.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.38 / $1,960.09 / $4,039.77
| Professional | | $1,573.38 | $1,960.09 | $4,039.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,856.35 / $4,856.35 / $4,856.35
| Facility | | $4,856.35 | $4,856.35 | $4,856.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.55 / $2,225.15 / $4,856.35
| Professional | | $2,187.55 | $2,225.15 | $4,856.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,141.52 / $3,141.52 / $3,575.13
| Facility | | $3,141.52 | $3,141.52 | $3,575.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.31 / $3,074.01 / $3,235.77
| Professional | | $2,293.31 | $3,074.01 | $3,235.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,700.56 / $3,885.08 / $6,313.26
| Professional | | $2,700.56 | $3,885.08 | $6,313.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.04 / $1,817.08 / $3,028.47
| Professional | | $1,680.04 | $1,817.08 | $3,028.47 |