- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,437.69 / $1,437.69 / $3,691.37
| Facility | | $1,437.69 | $1,437.69 | $3,691.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.69 / $1,996.88 / $3,691.37
| Professional | | $1,437.69 | $1,996.88 | $3,691.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,437.52 / $4,437.52 / $4,437.52
| Facility | | $4,437.52 | $4,437.52 | $4,437.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,439.35 / $2,731.58 / $5,415.33
| Professional | | $2,439.35 | $2,731.58 | $5,415.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $3,266.79
| Facility | | $2,941.06 | $2,941.06 | $3,266.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $5,270.63
| Professional | | $2,146.96 | $2,146.96 | $5,270.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.65 / $3,689.72 / $6,390.03
| Professional | | $2,467.65 | $3,689.72 | $6,390.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,586.52 / $2,061.76 / $3,100.69
| Professional | | $1,586.52 | $2,061.76 | $3,100.69 |