- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,338.09 / $1,338.09 / $3,435.65
| Facility | | $1,338.09 | $1,338.09 | $3,435.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.09 / $1,858.55 / $3,435.65
| Professional | | $1,338.09 | $1,858.55 | $3,435.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,130.10 / $4,130.10 / $4,130.10
| Facility | | $4,130.10 | $4,130.10 | $4,130.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.56 / $2,542.58 / $5,506.82
| Professional | | $2,480.56 | $2,542.58 | $5,506.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,040.49 / $3,148.57 / $3,148.57
| Facility | | $3,040.49 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $2,791.07 / $3,356.53
| Professional | | $2,298.46 | $2,791.07 | $3,356.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.71 / $3,434.11 / $5,947.36
| Professional | | $2,296.71 | $3,434.11 | $5,947.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.32 / $2,060.46 / $3,153.07
| Professional | | $1,613.32 | $2,060.46 | $3,153.07 |