- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.77 / $1,083.77 / $2,782.66
| Facility | | $1,083.77 | $1,083.77 | $2,782.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.77 / $1,505.31 / $2,782.66
| Professional | | $1,083.77 | $1,505.31 | $2,782.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,345.13 / $3,345.13 / $3,345.13
| Facility | | $3,345.13 | $3,345.13 | $3,345.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.86 / $1,838.86 / $4,082.24
| Professional | | $1,838.86 | $1,838.86 | $4,082.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $2,462.61
| Facility | | $2,217.07 | $2,217.07 | $2,462.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $2,169.42 / $2,363.51
| Professional | | $1,618.46 | $2,169.42 | $2,363.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.19 / $2,676.10 / $4,348.67
| Professional | | $1,860.19 | $2,676.10 | $4,348.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,153.33 / $2,018.42 / $2,291.16
| Facility | | $1,153.33 | $2,018.42 | $2,291.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.24 / $1,527.44 / $2,545.73
| Professional | | $1,412.24 | $1,527.44 | $2,545.73 |