- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,205.21 / $1,205.21 / $3,094.46
| Facility | | $1,205.21 | $1,205.21 | $3,094.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.21 / $1,673.99 / $3,094.46
| Professional | | $1,205.21 | $1,673.99 | $3,094.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,719.97 / $3,719.97 / $3,719.97
| Facility | | $3,719.97 | $3,719.97 | $3,719.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,053.24 / $3,053.24 / $6,099.77
| Professional | | $3,053.24 | $3,053.24 | $6,099.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $2,381.07 / $2,738.56
| Facility | | $2,381.07 | $2,381.07 | $2,738.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.56 / $1,738.18 / $2,452.50
| Professional | | $299.56 | $1,738.18 | $2,452.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.63 / $3,093.08 / $5,356.76
| Professional | | $2,068.63 | $3,093.08 | $5,356.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.32 / $1,699.03 / $2,831.71
| Professional | | $1,330.32 | $1,699.03 | $2,831.71 |