- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,205.34 / $1,205.34 / $3,094.82
| Facility | | $1,205.34 | $1,205.34 | $3,094.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.34 / $1,674.18 / $3,094.82
| Professional | | $1,205.34 | $1,674.18 | $3,094.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,720.40 / $3,720.40 / $3,720.40
| Facility | | $3,720.40 | $3,720.40 | $3,720.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.04 / $1,970.30 / $4,292.66
| Professional | | $1,934.04 | $1,970.30 | $4,292.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,861.13 / $2,861.13 / $2,861.13
| Facility | | $2,861.13 | $2,861.13 | $2,861.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.96 / $2,431.96 / $2,946.96
| Professional | | $2,431.96 | $2,431.96 | $2,946.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.86 / $2,976.32 / $4,836.52
| Professional | | $2,068.86 | $2,976.32 | $4,836.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.61 / $1,634.33 / $2,485.87
| Professional | | $1,257.61 | $1,634.33 | $2,485.87 |