- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,890.45
| Facility | | $2,818.38 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $2,818.38
| Professional | | $1,318.26 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $3,388.44
| Facility | | $2,511.89 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,019.95
| Professional | | $2,238.72 | $2,238.72 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $4,168.69
| Facility | | $1,445.44 | $1,778.28 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,238.72
| Facility | | $1,995.26 | $1,995.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,238.72
| Professional | | $933.25 | $1,318.26 | $2,238.72 |