- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,257.43 / $1,257.43 / $3,228.54
| Facility | | $1,257.43 | $1,257.43 | $3,228.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.43 / $1,746.51 / $3,228.54
| Professional | | $1,257.43 | $1,746.51 | $3,228.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,881.14 / $3,881.14 / $3,881.14
| Facility | | $3,881.14 | $3,881.14 | $3,881.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.55 / $2,072.57 / $4,523.34
| Professional | | $2,037.55 | $2,072.57 | $4,523.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,782.58 / $2,782.58 / $2,857.20
| Facility | | $2,782.58 | $2,782.58 | $2,857.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.28 / $2,031.28 / $3,815.62
| Professional | | $2,031.28 | $2,031.28 | $3,815.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,158.25 / $3,104.91 / $5,045.47
| Professional | | $2,158.25 | $3,104.91 | $5,045.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.20 / $1,692.48 / $2,608.07
| Professional | | $1,325.20 | $1,692.48 | $2,608.07 |