- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,104.75 / $1,104.75 / $2,836.52
| Facility | | $1,104.75 | $1,104.75 | $2,836.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.75 / $1,534.45 / $2,836.52
| Professional | | $1,104.75 | $1,534.45 | $2,836.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,409.89 / $3,409.89 / $3,409.89
| Facility | | $3,409.89 | $3,409.89 | $3,409.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.54 / $1,929.14 / $4,210.30
| Professional | | $1,896.54 | $1,929.14 | $4,210.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,510.27
| Facility | | $2,425.11 | $2,425.11 | $2,510.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,253.59 / $2,497.86
| Professional | | $1,770.33 | $2,253.59 | $2,497.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.19 / $2,727.91 / $4,432.85
| Professional | | $1,896.19 | $2,727.91 | $4,432.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.49 / $1,695.04 / $2,427.57
| Professional | | $1,233.49 | $1,695.04 | $2,427.57 |