- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,679.37 / $1,679.37 / $4,311.89
| Facility | | $1,679.37 | $1,679.37 | $4,311.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.37 / $2,332.57 / $4,311.89
| Professional | | $1,679.37 | $2,332.57 | $4,311.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,183.47 / $5,183.47 / $5,183.47
| Facility | | $5,183.47 | $5,183.47 | $5,183.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,694.05 / $2,694.05 / $5,980.75
| Professional | | $2,694.05 | $2,694.05 | $5,980.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $3,815.95
| Facility | | $2,802.84 | $2,802.84 | $3,815.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,382.41 / $2,886.93
| Professional | | $2,382.41 | $2,382.41 | $2,886.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,882.47 / $4,146.78 / $6,738.52
| Professional | | $2,882.47 | $4,146.78 | $6,738.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.18 / $2,237.80 / $3,463.45
| Professional | | $1,752.18 | $2,237.80 | $3,463.45 |