- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.02 / $1,204.02 / $3,091.40
| Facility | | $1,204.02 | $1,204.02 | $3,091.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.02 / $1,672.33 / $3,091.40
| Professional | | $1,204.02 | $1,672.33 | $3,091.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,716.28 / $3,716.28 / $3,716.28
| Facility | | $3,716.28 | $3,716.28 | $3,716.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,042.96 / $2,068.50 / $4,535.18
| Professional | | $2,042.96 | $2,068.50 | $4,535.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $2,735.84
| Facility | | $2,463.07 | $2,463.07 | $2,735.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $2,410.14 / $2,625.75
| Professional | | $1,798.04 | $2,410.14 | $2,625.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.58 / $2,973.02 / $4,831.16
| Professional | | $2,066.58 | $2,973.02 | $4,831.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.66 / $1,825.82 / $2,614.89
| Professional | | $1,328.66 | $1,825.82 | $2,614.89 |