- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,384.69 / $2,384.69 / $3,720.13
| Facility | | $2,384.69 | $2,384.69 | $3,720.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.23 / $2,384.69 / $2,384.69
| Professional | | $2,146.23 | $2,384.69 | $2,384.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,672.28 / $1,672.28 / $1,760.29
| Facility | | $1,672.28 | $1,672.28 | $1,760.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.28 / $1,760.29 / $1,957.97
| Professional | | $1,672.28 | $1,760.29 | $1,957.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,059.50 / $3,824.38 / $6,275.52
| Professional | | $3,059.50 | $3,824.38 | $6,275.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,384.69 / $2,384.69 / $4,381.89
| Facility | | $2,384.69 | $2,384.69 | $4,381.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,384.69 / $2,677.56 / $3,012.25
| Professional | | $2,384.69 | $2,677.56 | $3,012.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,673.47 / $2,789.12
| Professional | | $1,054.29 | $1,673.47 | $2,789.12 |